Basic Information
| Provider Information | |||||||||
| NPI: | 1962572172 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOGAN | ||||||||
| FirstName: | MARY JANE | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD, MPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 CEDAR ST | ||||||||
| Address2: | LMP 2073 | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065103206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037854640 | ||||||||
| FaxNumber: | 2037372228 | ||||||||
| Practice Location | |||||||||
| Address1: | 333 CEDAR ST | ||||||||
| Address2: | LMP 2073 | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065103206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037854640 | ||||||||
| FaxNumber: | 2037372228 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2006 | ||||||||
| LastUpdateDate: | 03/20/2013 | ||||||||
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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 | 2080P0207X | 037422 | CT | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Hematology-Oncology |
ID Information
| ID | Type | State | Issuer | Description | 001374222 | 05 | CT | MEDICAID |