Basic Information
Provider Information | |||||||||
NPI: | 1568468239 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WALALIYADDA | ||||||||
FirstName: | ANU | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 687 CAMPBELL AVE | ||||||||
Address2: |   | ||||||||
City: | WEST HAVEN | ||||||||
State: | CT | ||||||||
PostalCode: | 065163774 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2039326481 | ||||||||
FaxNumber: | 2038894953 | ||||||||
Practice Location | |||||||||
Address1: | 687 CAMPBELL AVE | ||||||||
Address2: |   | ||||||||
City: | WEST HAVEN | ||||||||
State: | CT | ||||||||
PostalCode: | 065163774 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2039326481 | ||||||||
FaxNumber: | 2038894953 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/27/2005 | ||||||||
LastUpdateDate: | 05/28/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/28/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 037039 | CT | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 0V7626 | 01 | CT | HEALTHNET | OTHER | P1943701 | 01 | CT | OXFORD | OTHER | 711781 | 01 | CT | CONNECTICARE | OTHER | 110169704 | 01 | CT | RAILROAD MEDICARE | OTHER | 2161149 | 01 | CT | AETNA | OTHER | 001370395 | 05 | CT |   | MEDICAID | 010037039CT01 | 01 | CT | ANTHEM BLUE SHIELD | OTHER |