Provider Demographics
NPI:1629055249
Name:VIRUET, IVELISSE AUBIN (MD)
Entity Type:Individual
Prefix:DR
First Name:IVELISSE
Middle Name:AUBIN
Last Name:VIRUET
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 1:153 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06042-3112
Mailing Address - Country:US
Mailing Address - Phone:860-432-5803
Mailing Address - Fax:
Practice Address - Street 1:153 MAIN ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06042-3112
Practice Address - Country:US
Practice Address - Phone:860-432-5803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT034410207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001344100Medicaid
CT010034410CT01OtherBC/BS
CT034410OtherMEDICAL LICENSE
CT034410OtherMEDICAL LICENSE
CTBV5024473OtherDEA
CTD400027940Medicare PIN
CT001344100Medicaid