Basic Information
| Provider Information | |||||||||
| NPI: | 1043448350 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GITTLEMAN | ||||||||
| FirstName: | COREY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6 BUTTRICK RD | ||||||||
| Address2: | STE 102 | ||||||||
| City: | LONDONDERRY | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030533417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035371300 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 28 CRESCENT ST | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064573654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603584820 | ||||||||
| FaxNumber: | 8603586748 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2009 | ||||||||
| LastUpdateDate: | 02/25/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 051762 | CT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.