1033633722 NPI number — DAVID C AVALLON

Table of content: DAVID C AVALLON (NPI 1033633722)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033633722 NPI number — DAVID C AVALLON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AVALLON
Provider First Name:
DAVID
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1033633722
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/24/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1220 POST ROAD
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
FAIRFIELD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06824
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-955-1147
Provider Business Mailing Address Fax Number:
203-955-1148

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 ATLANTIC ST STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STAMFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06901-2438
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-355-2225
Provider Business Practice Location Address Fax Number:
203-355-2235
Provider Enumeration Date:
08/03/2017

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: 111N00000X , with the licence number:  2079 , 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: 2079 . This is a "CONNECTICUT" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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