Basic Information
| Provider Information | |||||||||
| NPI: | 1548271687 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DE AZEVEDO | ||||||||
| FirstName: | JOAO | ||||||||
| MiddleName: | PAULO | ||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19 OLD QUARRY RD | ||||||||
| Address2: | |||||||||
| City: | WOODBRIDGE | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033933274 | ||||||||
| FaxNumber: | 2038675461 | ||||||||
| Practice Location | |||||||||
| Address1: | 1423 CHAPEL STREET | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037893538 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 017676 | CT | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 1176767 | 05 | CT | MEDICAID |