Provider Demographics
NPI:1174763957
Name:MA, HARRY (MD/PHD)
Entity type:Individual
Prefix:
First Name:HARRY
Middle Name:
Last Name:MA
Suffix:
Gender:M
Credentials:MD/PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 RESEARCH DR STE 105
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-6228
Mailing Address - Country:US
Mailing Address - Phone:203-210-6340
Mailing Address - Fax:
Practice Address - Street 1:2 SHAWS CV STE 203
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4975
Practice Address - Country:US
Practice Address - Phone:203-375-2861
Practice Address - Fax:203-375-5615
Is Sole Proprietor?:No
Enumeration Date:2009-03-06
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT55618174400000X, 2086S0129X
MA241896208600000X
NY248565-1208600000X
RIMD155972086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No174400000XOther Service ProvidersSpecialist
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD400335607Medicare PIN
CTD400335607Medicare PIN