Provider Demographics
NPI:1437132230
Name:NATHANSON, MICHAEL HARRIS (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:HARRIS
Last Name:NATHANSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 YORK ST
Mailing Address - Street 2:LMP - 180
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-3221
Mailing Address - Country:US
Mailing Address - Phone:203-785-4138
Mailing Address - Fax:203-737-1345
Practice Address - Street 1:15 YORK ST
Practice Address - Street 2:LMP - 180
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3221
Practice Address - Country:US
Practice Address - Phone:203-785-4138
Practice Address - Fax:203-737-1345
Is Sole Proprietor?:No
Enumeration Date:2005-11-25
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT029365207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001293654Medicaid
CT001293654Medicaid
E46115Medicare UPIN