Basic Information
Provider Information | |||||||||
NPI: | 1013199314 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | STATE OF CONNECITUT HEALTH CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 263 FARMINGTON AVE | ||||||||
Address2: | PROVIDER ENROLLMENT - DOWLING SOUTH | ||||||||
City: | FARMINGTON | ||||||||
State: | CT | ||||||||
PostalCode: | 060302212 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8606797503 | ||||||||
FaxNumber: | 8606791610 | ||||||||
Practice Location | |||||||||
Address1: | 263 FARMINGTON AVE | ||||||||
Address2: | INFECTIOUS DISEASES ASSOCIATES | ||||||||
City: | FARMINGTON | ||||||||
State: | CT | ||||||||
PostalCode: | 060300001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8606794225 | ||||||||
FaxNumber: | 8606791217 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/29/2007 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LAFRENIERE | ||||||||
AuthorizedOfficialFirstName: | DENIS | ||||||||
AuthorizedOfficialMiddleName: | C | ||||||||
AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 8606797503 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | STATE OF CONNECITUT HEALTH CENTER | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X |   | CT | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
No ID Information.