Basic Information
| Provider Information | |||||||||
| NPI: | 1629100086 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GARIBALDI | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRASCH | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 64 BLACK ROCK AVE | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066051200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035795000 | ||||||||
| FaxNumber: | 2035795113 | ||||||||
| Practice Location | |||||||||
| Address1: | 64 BLACK ROCK AVE | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035795000 | ||||||||
| FaxNumber: | 2035795113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2007 | ||||||||
| LastUpdateDate: | 08/05/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080A0000X | 64005 | CT | Y | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine |
ID Information
| ID | Type | State | Issuer | Description | 004234788 | 05 | CT | MEDICAID |