1790860419 NPI number — JOSEE DIANE CLOUTIER M.D.

Table of content: JOSEE DIANE CLOUTIER M.D. (NPI 1790860419)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790860419 NPI number — JOSEE DIANE CLOUTIER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLOUTIER
Provider First Name:
JOSEE
Provider Middle Name:
DIANE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.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:
1790860419
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10 LIBERTY WAY
Provider Second Line Business Mailing Address:
SUITE 10B
Provider Business Mailing Address City Name:
NIANTIC
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06357-1032
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-691-8084
Provider Business Mailing Address Fax Number:
860-691-1195

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10 LIBERTY WAY
Provider Second Line Business Practice Location Address:
SUITE 10B
Provider Business Practice Location Address City Name:
NIANTIC
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06357-1032
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-691-8084
Provider Business Practice Location Address Fax Number:
860-691-1195
Provider Enumeration Date:
10/25/2006

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: 207Q00000X , with the licence number:  040820 , 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: 010040820CT02 . This is a "ANTHEM BLUE CROSS" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 9727325 . This is a "CIGNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: P2706722 . This is a "OXFORD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 2V4806 . This is a "HEALTH NET" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 3581342 . This is a "AETNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 5534978 . This is a "FIRST HEALTH" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 134273740 . This is a "COMMERCIAL PLANS" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 040820 . This is a "CONNECTICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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