Provider Demographics
NPI:1689641821
Name:TOLA, VICKY B (MD)
Entity Type:Individual
Prefix:
First Name:VICKY
Middle Name:B
Last Name:TOLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:471 BARNUM AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06608-2409
Mailing Address - Country:US
Mailing Address - Phone:203-576-3885
Mailing Address - Fax:203-332-0376
Practice Address - Street 1:471 BARNUM AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06608-2409
Practice Address - Country:US
Practice Address - Phone:203-576-3885
Practice Address - Fax:203-332-0376
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT46163207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT207Q00000XMedicare Oscar/Certification
H74693Medicare UPIN