1700880580 NPI number — DR. EZRA DOTTINO D.P.M.

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 1700880580 NPI number — DR. EZRA DOTTINO D.P.M.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOTTINO
Provider First Name:
EZRA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.P.M.
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:
1700880580
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/12/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
777 ECHO LAKE RD UNIT F
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WATERTOWN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06795-6618
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-274-1773
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
777 ECHO LAKE RD UNIT F
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATERTOWN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06795
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-274-1773
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/09/2005

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: 213E00000X , with the licence number:  000686 , 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: 004178126 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 030000686CT03 . This is a "BLUE CROSS AND SHEILD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7571237 . This is a "CIGNA HEALTH PLANS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5394697 . This is a "AETNA HEALTH PLANS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2V5210 . This is a "HEALTHNET" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00144204 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: P3348525 . This is a "OXFORD HEALTH PLANS" identifier . This identifiers is of the category "OTHER".




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