Provider Demographics
NPI:1255358230
Name:MORO-DE-CASILLAS, MARIA L (MD)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:L
Last Name:MORO-DE-CASILLAS
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 1:100 PERKINS FARM DRIVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MYSTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06355
Mailing Address - Country:US
Mailing Address - Phone:860-886-1433
Mailing Address - Fax:860-886-4644
Practice Address - Street 1:100 PERKINS FARM DRIVE
Practice Address - Street 2:SUITE 103
Practice Address - City:MYSTIC
Practice Address - State:CT
Practice Address - Zip Code:06355
Practice Address - Country:US
Practice Address - Phone:860-870-6385
Practice Address - Fax:860-245-0000
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT443912084N0400X
RIMD119912084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001443910Medicaid
RI007058826Medicare PIN
CT001443910Medicaid