Provider Demographics
NPI:1356758387
Name:AGUILAR TEJEDOR, IDAIRA (MD)
Entity type:Individual
Prefix:
First Name:IDAIRA
Middle Name:
Last Name:AGUILAR TEJEDOR
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 1:99 HAWLEY LN STE 1120
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06614-1208
Mailing Address - Country:US
Mailing Address - Phone:203-377-5988
Mailing Address - Fax:
Practice Address - Street 1:99 HAWLEY LN STE 1120
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06614-1208
Practice Address - Country:US
Practice Address - Phone:203-377-5988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-22
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT641812084N0400X, 2084N0008X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0008XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeuromuscular Medicine
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty