Basic Information
| Provider Information | |||||||||
| NPI: | 1851666085 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OUELLET | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 874 HOWARD AVE | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065191106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036889423 | ||||||||
| FaxNumber: | 2036884209 | ||||||||
| Practice Location | |||||||||
| Address1: | 874 HOWARD AVE | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036889423 | ||||||||
| FaxNumber: | 2036884209 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2012 | ||||||||
| LastUpdateDate: | 07/11/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RG0300X | 54320 | CT | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
No ID Information.