Basic Information
| Provider Information | |||||||||
| NPI: | 1851375612 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IMAEDA | ||||||||
| FirstName: | AVLIN | ||||||||
| MiddleName: | BARLOW | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 237 LANDON'S WAY | ||||||||
| Address2: | |||||||||
| City: | GUILFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064374362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037857998 | ||||||||
| FaxNumber: | 2037856414 | ||||||||
| Practice Location | |||||||||
| Address1: | 950 CAMPBELL AVE | ||||||||
| Address2: | VA CT HEALTHCARE | ||||||||
| City: | WEST HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065162770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2039325711 | ||||||||
| FaxNumber: | 2039373873 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2005 | ||||||||
| LastUpdateDate: | 04/25/2011 | ||||||||
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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 | 207R00000X | 041499 | CT | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0100X | 041499 | CT | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 001414995 | 05 | CT | MEDICAID |