1720113723 NPI number — LAURA M MARTINEAU OTR

Table of content: LAURA M MARTINEAU OTR (NPI 1720113723)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720113723 NPI number — LAURA M MARTINEAU OTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTINEAU
Provider First Name:
LAURA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTR
Provider Gender Code:
F

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:
1720113723
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
203 BROAD ST
Provider Second Line Business Mailing Address:
UNIT C-2
Provider Business Mailing Address City Name:
MILFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06460-4751
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-876-2000
Provider Business Mailing Address Fax Number:
203-876-1545

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 N PLAINS INDUSTRIAL RD
Provider Second Line Business Practice Location Address:
BUILDING 2
Provider Business Practice Location Address City Name:
WALLINGFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06492-2360
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-949-9337
Provider Business Practice Location Address Fax Number:
203-284-3779
Provider Enumeration Date:
02/22/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225XP0200X , with the licence number:  002747 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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