Basic Information
Provider Information | |||||||||
NPI: | 1396722575 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VAEZY | ||||||||
FirstName: | ALI | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 20 YORK ST | ||||||||
Address2: | YNHH WEST PAVILION, 2ND FL | ||||||||
City: | NEW HAVEN | ||||||||
State: | CT | ||||||||
PostalCode: | 065103220 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2037854081 | ||||||||
FaxNumber: | 2037372228 | ||||||||
Practice Location | |||||||||
Address1: | 20 YORK ST | ||||||||
Address2: | YNHH WEST PAVILION, 2ND FL | ||||||||
City: | NEW HAVEN | ||||||||
State: | CT | ||||||||
PostalCode: | 065103220 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2037854081 | ||||||||
FaxNumber: | 2037372228 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/28/2005 | ||||||||
LastUpdateDate: | 10/29/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/29/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 040741 | CT | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 001407411 | 05 | CT |   | MEDICAID | 220133 | 01 | CT | WELLCARE | OTHER | 3408207/7603504 | 01 | CT | AETNA | OTHER | 23-33843 | 01 | CT | UHC | OTHER | PENDING | 01 | CT | RR MEDICARE | OTHER | 23-33843 | 01 | CT | AMERICHOICE | OTHER | 912708 | 01 | CT | USA | OTHER | 010040741CT02 | 01 | CT | ANTHEM BCBS CT | OTHER | 040741 | 01 | CT | CONNECTICARE | OTHER | 2V1459 | 01 | CT | HEALTHNET/COMMERCIAL | OTHER | P2978576 | 01 | CT | OXFORD | OTHER |