1407944689 NPI number — DIABETES AND ENDOCRINOLOGY OF NORTHWESTERN CONNECTICUT

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407944689 NPI number — DIABETES AND ENDOCRINOLOGY OF NORTHWESTERN CONNECTICUT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIABETES AND ENDOCRINOLOGY OF NORTHWESTERN CONNECTICUT
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:
1407944689
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/09/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
780 LITCHFIELD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TORRINGTON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06790-6268
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-496-2198
Provider Business Mailing Address Fax Number:
860-489-2482

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
780 LITCHFIELD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TORRINGTON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06790-6268
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-496-2198
Provider Business Practice Location Address Fax Number:
860-489-2482
Provider Enumeration Date:
10/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BOGDANOVICS
Authorized Official First Name:
EGILS
Authorized Official Middle Name:
KNUTS
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
860-496-2198

Provider Taxonomy Codes

  • Taxonomy code: 207RE0101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7133354 . This is a "AETNA CLAIMS ID" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 4311104 . This is a "AETNA EDI ID" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 3000 . This is a "NEIC SITE ID, NSF BAO-7" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 001312660 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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