Provider Demographics
NPI:1679589956
Name:FAZALUD-DIN, PRIMLA (MD)
Entity type:Individual
Prefix:
First Name:PRIMLA
Middle Name:
Last Name:FAZALUD-DIN
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 1:675 TOWER AVENUE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06112
Mailing Address - Country:US
Mailing Address - Phone:860-714-2750
Mailing Address - Fax:860-714-8591
Practice Address - Street 1:31 SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-4540
Practice Address - Country:US
Practice Address - Phone:860-714-2750
Practice Address - Fax:860-714-8591
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0240192084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry