1538249065 NPI number — GEOFFREY L MANTON MD

Table of content: GEOFFREY L MANTON MD (NPI 1538249065)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538249065 NPI number — GEOFFREY L MANTON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANTON
Provider First Name:
GEOFFREY
Provider Middle Name:
L
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:
1538249065
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/17/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
385 MAIN ST SOUTH
Provider Second Line Business Mailing Address:
UNION SQUARE BLDG #1, NVRA IMAGING NETWORK
Provider Business Mailing Address City Name:
SOUTHBURY
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06488
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-264-7999
Provider Business Mailing Address Fax Number:
203-264-7477

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
385 MAIN ST SOUTH
Provider Second Line Business Practice Location Address:
UNION SQUARE
Provider Business Practice Location Address City Name:
SOUTHBURY
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06488
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-264-7999
Provider Business Practice Location Address Fax Number:
203-264-7477
Provider Enumeration Date:
10/17/2006

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: 2085B0100X , with the licence number:  043995 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085N0904X , with the licence number: 043995 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: 043995 , 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: 001439951 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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