Provider Demographics
NPI:1174514566
Name:LANDRY, MARIE L (MD)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:L
Last Name:LANDRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9805
Mailing Address - Street 2:300 GEORGE ST, 6TH FLOOR
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06536-0805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 YORK STREET
Practice Address - Street 2:YALE NEW HAVEN HOSPITAL-CB 407
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1369
Practice Address - Country:US
Practice Address - Phone:203-688-3475
Practice Address - Fax:203-688-8177
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2008-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT019372207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001193721Medicaid
CT110006556Medicare ID - Type Unspecified
E31372Medicare UPIN