1154765998 NPI number — REESE PRESCOTT ISAACSON

Table of content: REESE PRESCOTT ISAACSON (NPI 1154765998)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154765998 NPI number — REESE PRESCOTT ISAACSON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ISAACSON
Provider First Name:
REESE
Provider Middle Name:
PRESCOTT
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:
1154765998
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1200 N STATE ST
Provider Second Line Business Mailing Address:
CT-A7D
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90033-1029
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
323-226-7556
Provider Business Mailing Address Fax Number:
323-226-2657

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
64 ROBBINS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATERBURY
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06708-2613
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-573-6232
Provider Business Practice Location Address Fax Number:
203-573-6030
Provider Enumeration Date:
04/23/2013

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: 390200000X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X , with the licence number: 56916 , 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: RI3232267556 . This is a "USC" identifier . This identifiers is of the category "OTHER".




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