Provider Demographics
NPI:1851375612
Name:IMAEDA, AVLIN BARLOW (MD)
Entity Type:Individual
Prefix:
First Name:AVLIN
Middle Name:BARLOW
Last Name:IMAEDA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:237 LANDON'S WAY
Mailing Address - Street 2:
Mailing Address - City:GUILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06437-4362
Mailing Address - Country:US
Mailing Address - Phone:203-785-7998
Mailing Address - Fax:203-785-6414
Practice Address - Street 1:950 CAMPBELL AVE
Practice Address - Street 2:VA CT HEALTHCARE
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-2770
Practice Address - Country:US
Practice Address - Phone:203-932-5711
Practice Address - Fax:203-937-3873
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT041499207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001414995Medicaid
CT001414995Medicaid
CT110009099Medicare ID - Type Unspecified