Basic Information
| Provider Information | |||||||||
| NPI: | 1710968961 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FIEL-GAN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | DESIREE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 99 EAST RIVER DR | ||||||||
| Address2: | 5TH FLOOR | ||||||||
| City: | EAST HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061087301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602824133 | ||||||||
| FaxNumber: | 8602890746 | ||||||||
| Practice Location | |||||||||
| Address1: | 99 E RIVER DR | ||||||||
| Address2: | 5TH FLOOR | ||||||||
| City: | EAST HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061083288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602824133 | ||||||||
| FaxNumber: | 8602890746 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2005 | ||||||||
| LastUpdateDate: | 12/16/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 037621 | CT | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 0-457-663-3 | 01 | ECFMG | OTHER | 001376210 | 05 | CT | MEDICAID |