Provider Demographics
NPI:1679701882
Name:SOUTHERN CONNECTICUT GERIATRIC & PREVENTIVE MEDICINE LLC
Entity type:Organization
Organization Name:SOUTHERN CONNECTICUT GERIATRIC & PREVENTIVE MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ASEFEH
Authorized Official - Middle Name:
Authorized Official - Last Name:HEIAT
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MPH
Authorized Official - Phone:203-871-9224
Mailing Address - Street 1:390 LIVINGSTON ST
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-1336
Mailing Address - Country:US
Mailing Address - Phone:203-871-9224
Mailing Address - Fax:
Practice Address - Street 1:390 LIVINGSTON ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-1336
Practice Address - Country:US
Practice Address - Phone:203-871-9224
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-25
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT041288207RG0300X, 2083P0901X
207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Multi-Specialty