1548240146 NPI number — HOPE BERNARD MARANDOLA O.D.

Table of content: HOPE BERNARD MARANDOLA O.D. (NPI 1548240146)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548240146 NPI number — HOPE BERNARD MARANDOLA O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARANDOLA
Provider First Name:
HOPE
Provider Middle Name:
BERNARD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.D.
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:
1548240146
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/14/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 545
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CENTRAL VILLAGE
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06332-0545
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-564-2709
Provider Business Mailing Address Fax Number:
860-564-4347

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10 NORWICH RD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CENTRAL VILLAGE
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06332-0545
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-564-2709
Provider Business Practice Location Address Fax Number:
860-564-4347
Provider Enumeration Date:
01/19/2006

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: 152W00000X , with the licence number:  002311 , 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: 004124343 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2V3741 . This is a "HEALTHNET" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: CT2311 . This is a "EYE MED" identifier . This identifiers is of the category "OTHER".
  • Identifier: 50890 . This is a "DAVIS VISION" identifier . This identifiers is of the category "OTHER".
  • Identifier: 090002311CT03 . This is a "ANTHEM BCBS" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 558369 . This is a "CONNECTICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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