1417900101 NPI number — DR. LAITH KASIR M.D.

Table of content: DR. LAITH KASIR M.D. (NPI 1417900101)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417900101 NPI number — DR. LAITH KASIR M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KASIR
Provider First Name:
LAITH
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1417900101
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/31/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
555 WILLARD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWINGTON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06111-2631
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-666-6951
Provider Business Mailing Address Fax Number:
860-667-6875

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
420 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRISTOL
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06010-4923
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-314-4400
Provider Business Practice Location Address Fax Number:
860-314-4407
Provider Enumeration Date:
05/17/2006

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: 207R00000X , with the licence number:  044097 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208M00000X , with the licence number: 044097 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 010044097CT02 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 49908884 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 044097 . This is a "CONNECTICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1415607 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5743576 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0014440974 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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