Basic Information
| Provider Information | |||||||||
| NPI: | 1922080647 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | GAETA | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | LOU | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9805 | ||||||||
| Address2: | 300 GEORGE STREET 6TH FLOOR | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065360805 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 20 YORK ST | ||||||||
| Address2: | YNHH (CHILDREN'S) WEST PAVILION | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065103220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037854651 | ||||||||
| FaxNumber: | 2037372786 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2005 | ||||||||
| LastUpdateDate: | 07/03/2008 | ||||||||
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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 | 2080P0203X | 035503 | CT | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 001355032 | 05 | CT | MEDICAID |