Provider Demographics
NPI:1710968961
Name:FIEL-GAN, MARY DESIREE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:DESIREE
Last Name:FIEL-GAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:99 EAST RIVER DR
Mailing Address - Street 2:5TH FLOOR
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-7301
Mailing Address - Country:US
Mailing Address - Phone:860-282-4133
Mailing Address - Fax:860-289-0746
Practice Address - Street 1:99 E RIVER DR
Practice Address - Street 2:5TH FLOOR
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06108-3288
Practice Address - Country:US
Practice Address - Phone:860-282-4133
Practice Address - Fax:860-289-0746
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT037621207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
0-457-663-3OtherECFMG
CT001376210Medicaid
G92379Medicare UPIN
CT001376210Medicaid