1255358230 NPI number — MARIA L. MORO-DE-CASILLAS MD

Table of content: MARIA L. MORO-DE-CASILLAS MD (NPI 1255358230)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255358230 NPI number — MARIA L. MORO-DE-CASILLAS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MORO-DE-CASILLAS
Provider First Name:
MARIA
Provider Middle Name:
L.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1255358230
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 PERKINS FARM DRIVE
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
MYSTIC
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06355
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-886-1433
Provider Business Mailing Address Fax Number:
860-886-4644

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 PERKINS FARM DRIVE
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
MYSTIC
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06355
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-870-6385
Provider Business Practice Location Address Fax Number:
860-245-0000
Provider Enumeration Date:
07/16/2006

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: 2084N0400X , with the licence number:  44391 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084N0400X , with the licence number: MD11991 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 001443910 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com