1063985323 NPI number — WATERTOWN MEDICAL ASSOCIATES, LLC

Table of content: (NPI 1063985323)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063985323 NPI number — WATERTOWN MEDICAL ASSOCIATES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WATERTOWN MEDICAL ASSOCIATES, LLC
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:
1063985323
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/29/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
365 MAIN ST STE 201
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:
06795-2249
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-274-2418
Provider Business Mailing Address Fax Number:
860-274-2986

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
365 MAIN ST STE 201
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:
06795-2249
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-274-2418
Provider Business Practice Location Address Fax Number:
860-274-2986
Provider Enumeration Date:
01/09/2019

Additional Information

Authorized Official

Authorized Official Last Name:
GOMEZ-TROCHEZ
Authorized Official First Name:
MAXIMILIAN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
860-274-2418

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 049979 . This is a "CONNECTICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 1154493 . This is a "USA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: P4376817 . This is a "OXFORD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 5856125 . This is a "CIGNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: P01040202 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 05856125 . This is a "GREAT WEST" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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