Basic Information
| Provider Information | |||||||||
| NPI: | 1710960935 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KERNAN | ||||||||
| FirstName: | WALTER | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 GEORGE ST | ||||||||
| Address2: | 6TH FLOOR | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065360805 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 789 HOWARD AVE | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065191304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036882471 | ||||||||
| FaxNumber: | 2036884516 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2005 | ||||||||
| LastUpdateDate: | 01/23/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 028405 | CT | N | Allopathic & Osteopathic Physicians | General Practice | 207R00000X | 28405 | CT | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 001284059 | 05 | CT | MEDICAID |