1992879795 NPI number — SOUTHERN CONNECTICUT DERMATOLOGY, P.C.

Table of content: MISS TIMYOTA MATTHEA SMITH LPN (NPI 1497291959)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992879795 NPI number — SOUTHERN CONNECTICUT DERMATOLOGY, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN CONNECTICUT DERMATOLOGY, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1992879795
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1275 SUMMER STREET
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
STAMFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06905
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-323-5660
Provider Business Mailing Address Fax Number:
203-323-8224

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1275 SUMMER STREET
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
STAMFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06905
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-323-5660
Provider Business Practice Location Address Fax Number:
203-323-8224
Provider Enumeration Date:
11/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
EVANS
Authorized Official First Name:
ROBIN
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
203-323-5660

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  030597 , 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)





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