1427030162 NPI number — OGNEN A C PETROFF MD

Table of content: OGNEN A C PETROFF MD (NPI 1427030162)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427030162 NPI number — OGNEN A C PETROFF MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETROFF
Provider First Name:
OGNEN
Provider Middle Name:
A C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1427030162
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
40 TEMPLE ST
Provider Second Line Business Mailing Address:
SUITE 6-C
Provider Business Mailing Address City Name:
NEW HAVEN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06510-2715
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-785-4085
Provider Business Mailing Address Fax Number:
203-737-1597

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
40 TEMPLE ST
Provider Second Line Business Practice Location Address:
SUITE 6-C
Provider Business Practice Location Address City Name:
NEW HAVEN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06510-2715
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-785-4085
Provider Business Practice Location Address Fax Number:
203-737-1597
Provider Enumeration Date:
11/17/2005

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: 2084N0400X , with the licence number:  023651 , 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: 001236512 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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