Provider Demographics
NPI:1629100086
Name:GARIBALDI, MARY L (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:L
Last Name:GARIBALDI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:L
Other - Last Name:BRASCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:64 BLACK ROCK AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06605-1200
Mailing Address - Country:US
Mailing Address - Phone:203-579-5000
Mailing Address - Fax:203-579-5113
Practice Address - Street 1:64 BLACK ROCK AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06605
Practice Address - Country:US
Practice Address - Phone:203-579-5000
Practice Address - Fax:203-579-5113
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT640052080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004234788Medicaid
NY01687654Medicaid
NY7712434OtherAETNA