1720154321 NPI number — EYE CENTER OF SOUTHERN CONNECTICUT, PC

Table of content: (NPI 1720154321)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720154321 NPI number — EYE CENTER OF SOUTHERN CONNECTICUT, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EYE CENTER OF SOUTHERN CONNECTICUT, PC
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:
6
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:
1720154321
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/04/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
150 SARGENT DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW HAVEN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06511
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-781-4307
Provider Business Mailing Address Fax Number:
203-781-4301

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2880 OLD DIXWELL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAMDEN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06518-3144
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-248-6365
Provider Business Practice Location Address Fax Number:
203-281-2742
Provider Enumeration Date:
11/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MASI
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
203-248-6365

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 004067435 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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