1972974830 NPI number — CONNECTICUT PODIATRY GROUP,P.C.

Table of content: (NPI 1972974830)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972974830 NPI number — CONNECTICUT PODIATRY GROUP,P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CONNECTICUT PODIATRY GROUP,P.C.
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:
1972974830
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/16/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
385 MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST HAVEN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06516-4312
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-933-8606
Provider Business Mailing Address Fax Number:
203-932-9571

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
128 SALTONSTALL PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST HAVEN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06512-2425
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-467-8606
Provider Business Practice Location Address Fax Number:
203-467-7256
Provider Enumeration Date:
10/16/2015

Additional Information

Authorized Official

Authorized Official Last Name:
DADDIO
Authorized Official First Name:
MARK
Authorized Official Middle Name:
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
203-933-8606

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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