1174595490 NPI number — DIMITRI GHECAS PA-C

Table of content: DIMITRI GHECAS PA-C (NPI 1174595490)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174595490 NPI number — DIMITRI GHECAS PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GHECAS
Provider First Name:
DIMITRI
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1174595490
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/18/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11 OLD PARK LANE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW MILFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06776
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-355-1149
Provider Business Mailing Address Fax Number:
860-355-5957

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11 OLD PARK LANE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW MILFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06776
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-355-1149
Provider Business Practice Location Address Fax Number:
860-355-5957
Provider Enumeration Date:
02/02/2006

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: 363AM0700X , with the licence number:  00735 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 022592 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00735 . This is a "CT LICENSE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: P2737999 . This is a "OXFORD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 2V3651 . This is a "ACS/HEALTHNET" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 713282 . This is a "CONNECTICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 290000735CT01 . This is a "ANTHEM BC/BS" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: P00006823 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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