Provider Demographics
NPI:1851350011
Name:PRONOVOST, MARY T (MD)
Entity Type:Individual
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First Name:MARY
Middle Name:T
Last Name:PRONOVOST
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Gender:F
Credentials:MD
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Mailing Address - Street 1:5520 PARK AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-3463
Mailing Address - Country:US
Mailing Address - Phone:203-254-2381
Mailing Address - Fax:203-255-8515
Practice Address - Street 1:226 MILL HILL AVE
Practice Address - Street 2:3RD FLOOR
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06610-2811
Practice Address - Country:US
Practice Address - Phone:203-384-3873
Practice Address - Fax:203-384-3829
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2016-09-16
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Provider Licenses
StateLicense IDTaxonomies
CT037703208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001377036Medicaid
CTG14485Medicare UPIN
CT001377036Medicaid