1265414114 NPI number — DR. STEWART EDWARD GALEUCIA OD

Table of content: DR. STEWART EDWARD GALEUCIA OD (NPI 1265414114)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265414114 NPI number — DR. STEWART EDWARD GALEUCIA OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GALEUCIA
Provider First Name:
STEWART
Provider Middle Name:
EDWARD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
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:
1265414114
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/20/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
85 RIVER RD
Provider Second Line Business Mailing Address:
APT K2
Provider Business Mailing Address City Name:
ESSEX
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06426-1345
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-215-0256
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
150 GOLD STAR HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GROTON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06340-3442
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-448-2022
Provider Business Practice Location Address Fax Number:
508-484-2008
Provider Enumeration Date:
11/16/2005

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: 152W00000X , with the licence number:  002803 , 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: 0348023 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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