Provider Demographics
NPI:1578553707
Name:MADRID, TANYA M (MD)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:M
Last Name:MADRID
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:292 LONG RIDGE RD STE 103
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-1627
Mailing Address - Country:US
Mailing Address - Phone:203-348-9455
Mailing Address - Fax:203-348-9183
Practice Address - Street 1:292 LONG RIDGE RD STE 103
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-1627
Practice Address - Country:US
Practice Address - Phone:203-348-9455
Practice Address - Fax:203-348-9183
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY211428207R00000X
CT69122207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02094613Medicaid
NY62C881Medicare ID - Type Unspecified