Provider Demographics
NPI:1770597593
Name:REGO, MARK D (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:REGO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-4296
Mailing Address - Country:US
Mailing Address - Phone:203-931-1184
Mailing Address - Fax:203-931-0063
Practice Address - Street 1:415 MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-4296
Practice Address - Country:US
Practice Address - Phone:203-931-1184
Practice Address - Fax:203-931-0063
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2013-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0282932084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001282938Medicaid
D80853Medicare UPIN
CT001282938Medicaid