Provider Demographics
NPI:1659884690
Name:NOVA VITA MEDICAL PC
Entity Type:Organization
Organization Name:NOVA VITA MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:UBONG
Authorized Official - Middle Name:JACKSON
Authorized Official - Last Name:UDOYEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-870-1616
Mailing Address - Street 1:3180 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-4237
Mailing Address - Country:US
Mailing Address - Phone:203-870-1616
Mailing Address - Fax:203-870-1615
Practice Address - Street 1:3180 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606
Practice Address - Country:US
Practice Address - Phone:203-870-1616
Practice Address - Fax:203-870-1615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-13
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT505532084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT50553OtherSTATE LICENSE