Provider Demographics
NPI:1679660021
Name:IMEVBORE, MICHAEL A (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:IMEVBORE
Suffix:
Gender:M
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:PO BOX 8478
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06530-0478
Mailing Address - Country:US
Mailing Address - Phone:203-786-5067
Mailing Address - Fax:203-786-5162
Practice Address - Street 1:46 PRINCE ST
Practice Address - Street 2:SUITE 306
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1600
Practice Address - Country:US
Practice Address - Phone:203-786-5067
Practice Address - Fax:203-786-5162
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT042335 CT207RP1001X
CT042335207RC0200X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001423350Medicaid
CT36951OtherCONTROLLED SUBSTANCE NO
CTBI9190149OtherFED DEA
CT110009658Medicare ID - Type Unspecified
I42435Medicare UPIN