Basic Information
| Provider Information | |||||||||
| NPI: | 1306116389 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PANISELLO | ||||||||
| FirstName: | JOSE | ||||||||
| MiddleName: | MANUEL | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 YORK STREET, | ||||||||
| Address2: | LLCI 305 PEDIATRICS, YALE UNIVERSITY | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065208064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037854651 | ||||||||
| FaxNumber: | 2037855833 | ||||||||
| Practice Location | |||||||||
| Address1: | 20 YORK ST | ||||||||
| Address2: | 305 LCI | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065103220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037854651 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2012 | ||||||||
| LastUpdateDate: | 04/05/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0203X | 050338 | CT | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine |
No ID Information.