Basic Information
| Provider Information | |||||||||
| NPI: | 1770017089 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | IBAD | ||||||||
| FirstName: | AWAIS | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1290 SILAS DEANE HWY | ||||||||
| Address2: | HHC CVO ENROLLMENT 1ST FLOOR | ||||||||
| City: | WETHERSFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8609726970 | ||||||||
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| Practice Location | |||||||||
| Address1: | 676 HEBRON AVE | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | GLASTONBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060332410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606962250 | ||||||||
| FaxNumber: | 8602245957 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2017 | ||||||||
| LastUpdateDate: | 08/26/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | 066465 | CT | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.