1962919605 NPI number — MRS. KATHARINA ERNST-SIXTO LICENSED OPTICIAN

Table of content: MRS. KATHARINA ERNST-SIXTO LICENSED OPTICIAN (NPI 1962919605)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962919605 NPI number — MRS. KATHARINA ERNST-SIXTO LICENSED OPTICIAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ERNST-SIXTO
Provider First Name:
KATHARINA
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LICENSED OPTICIAN
Provider Gender Code:
F

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:
1962919605
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
495 HAWLEY LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STRATFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06614-1514
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-375-5819
Provider Business Mailing Address Fax Number:
203-377-4337

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
495 HAWLEY LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STRATFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06614-1514
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-375-5819
Provider Business Practice Location Address Fax Number:
203-377-4337
Provider Enumeration Date:
01/03/2018

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: 156FX1800X , with the licence number:  001623 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332H00000X , with the licence number: 001623 , 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: 1114438652 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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