Provider Demographics
NPI:1508876103
Name:EASTSHORE PEDIATRICS
Entity Type:Organization
Organization Name:EASTSHORE PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAN
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:FUGAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-878-5941
Mailing Address - Street 1:1556 NEW HAVEN AVE
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460-8220
Mailing Address - Country:US
Mailing Address - Phone:203-878-5941
Mailing Address - Fax:
Practice Address - Street 1:1556 NEW HAVEN AVE
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06460-8220
Practice Address - Country:US
Practice Address - Phone:203-878-5941
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT16917OtherCDS
CT16917OtherCDS
CT16917OtherCDS