Provider Demographics
NPI:1750727178
Name:DIECKMAN, ELIZABETH A (MD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:DIECKMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:226 MILL HILL AVE
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06610-2826
Mailing Address - Country:US
Mailing Address - Phone:203-287-5400
Mailing Address - Fax:203-281-3001
Practice Address - Street 1:2200 WHITNEY AVE
Practice Address - Street 2:SUITE 240
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-3691
Practice Address - Country:US
Practice Address - Phone:203-287-5400
Practice Address - Fax:203-281-3001
Is Sole Proprietor?:No
Enumeration Date:2013-05-13
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT055188208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program