1497774657 NPI number — KISMATKUMAR DETROJA MD

Table of content: KISMATKUMAR DETROJA MD (NPI 1497774657)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497774657 NPI number — KISMATKUMAR DETROJA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DETROJA
Provider First Name:
KISMATKUMAR
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1497774657
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/21/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
170 TALCOTT RIDGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH WINDSOR
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06074-2386
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-794-9160
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 SILVER STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIDDLETOWN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06457
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-951-4954
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/19/2006

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:  044462 , 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)

  • Identifier: 010044462CT01 . This is a "BCBS" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 001444629 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 144462 . This is a "CONNECTICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 1497774657 . This is a "CHN" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 149777465 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 207787971 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 41044914 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7382858 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 581828 . This is a "HMN" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 7382858 . This is a "AETNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 1497774657 . This is a "CIGNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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