1881858959 NPI number — CONNECTICUT FOOT SPECIALISTS PC

Table of content: (NPI 1881858959)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881858959 NPI number — CONNECTICUT FOOT SPECIALISTS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CONNECTICUT FOOT SPECIALISTS 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:
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:
1881858959
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
133 HARTFORD AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAST GRANBY
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06026
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-653-4708
Provider Business Mailing Address Fax Number:
860-653-6249

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
259 ALBANY TURNPIKE
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
CANTON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06019
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-653-4708
Provider Business Practice Location Address Fax Number:
860-653-6249
Provider Enumeration Date:
07/17/2008

Additional Information

Authorized Official

Authorized Official Last Name:
WAGNER
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
K
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
860-653-4708

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , 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: 1093743502 . This is a "NPI # DR. WAGNER" identifier . This identifiers is of the category "OTHER".
  • Identifier: CT000793 . This is a "STATE LICENSE DR. WAGNER" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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