Basic Information
| Provider Information | |||||||||
| NPI: | 1275554958 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YAAKOV-BLECHMAN | ||||||||
| FirstName: | MIRALLE | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2800 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066064201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035766133 | ||||||||
| FaxNumber: | 2038633821 | ||||||||
| Practice Location | |||||||||
| Address1: | 2800 MAIN STREET | ||||||||
| Address2: | EMERGENCY DEPARTMENT SAINT VINCENT MEDICAL CENTER | ||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035766000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 02/03/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 038554 | CT | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02354676 | 05 | NY | MEDICAID |