1629561428 NPI number — OPTOMETRIC SPECIALTY GROUP OF WETHERSFIELD, PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629561428 NPI number — OPTOMETRIC SPECIALTY GROUP OF WETHERSFIELD, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPTOMETRIC SPECIALTY GROUP OF WETHERSFIELD, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1629561428
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/07/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
612 QUAKER LN S STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST HARTFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06110-1027
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-236-1218
Provider Business Mailing Address Fax Number:
860-231-9298

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
185 SILAS DEANE HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WETHERSFIELD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06109-1219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-296-1700
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/07/2018

Additional Information

Authorized Official

Authorized Official Last Name:
PEGOLO
Authorized Official First Name:
PETER
Authorized Official Middle Name:
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
860-236-1218

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , 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)





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