1528161551 NPI number — DERMATOLOGY ASSOCIATES OF WTBY PC

Table of content: (NPI 1528161551)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528161551 NPI number — DERMATOLOGY ASSOCIATES OF WTBY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DERMATOLOGY ASSOCIATES OF WTBY PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528161551
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
171 GRANDVIEW AVE
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
WATERBURY
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06708-2517
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-757-8919
Provider Business Mailing Address Fax Number:
203-756-4697

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
171 GRANDVIEW AVE
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
WATERBURY
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06708-2517
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-757-8919
Provider Business Practice Location Address Fax Number:
203-756-4697
Provider Enumeration Date:
09/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ROMANO
Authorized Official First Name:
SALVATORE
Authorized Official Middle Name:
V
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
203-757-8919

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 07D0100073 . This is a "BLUE CROSS NUMBER CLIA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 004001756 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 070000151 . This is a "MEDICARE GROUP #" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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