Basic Information
| Provider Information | |||||||||
| NPI: | 1871025973 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MODESTE | ||||||||
| FirstName: | TRACEY | ||||||||
| MiddleName: | MELISSA | ||||||||
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| OtherLastName: | GAFF | ||||||||
| OtherFirstName: | TRACEY | ||||||||
| OtherMiddleName: | MELLISA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 64 ROBBINS STREET | ||||||||
| Address2: | WATERBURY HOSPITAL, | ||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035736162 | ||||||||
| FaxNumber: | 2035736707 | ||||||||
| Practice Location | |||||||||
| Address1: | 305 CHURCH ST STE 15 | ||||||||
| Address2: | |||||||||
| City: | NAUGATUCK | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067702836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037296641 | ||||||||
| FaxNumber: | 2035755206 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2017 | ||||||||
| LastUpdateDate: | 01/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/21/2022 | ||||||||
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 | 66924 | CT | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.