Provider Demographics
NPI:1336241033
Name:FUGAL, JAN PETER (MD)
Entity Type:Individual
Prefix:DR
First Name:JAN
Middle Name:PETER
Last Name:FUGAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1556 NEW HAVEN AVE
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460-8220
Mailing Address - Country:US
Mailing Address - Phone:203-878-5941
Mailing Address - Fax:
Practice Address - Street 1:1556 NEW HAVEN AVE
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06460-8220
Practice Address - Country:US
Practice Address - Phone:203-878-5941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT013520207R00000X, 207RA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT013520OtherCT STATE LICENSE
AF1563584OtherDEA
AF1563584OtherDEA