Provider Demographics
NPI:1659404481
Name:TENNYSON, GARY SCOTT (PHD, MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:SCOTT
Last Name:TENNYSON
Suffix:
Gender:M
Credentials:PHD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 NICKEL MINE DR
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:CT
Mailing Address - Zip Code:06483-2472
Mailing Address - Country:US
Mailing Address - Phone:203-953-1200
Mailing Address - Fax:
Practice Address - Street 1:1 FOREST PKWY
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484-6147
Practice Address - Country:US
Practice Address - Phone:203-926-7143
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT040058207ZP0102X
FLME65534207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology