Basic Information
| Provider Information | |||||||||
| NPI: | 1144280637 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAIOCCO | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4639 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066061838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033745546 | ||||||||
| FaxNumber: | 2033714056 | ||||||||
| Practice Location | |||||||||
| Address1: | 4639 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066061838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033745546 | ||||||||
| FaxNumber: | 2033714056 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2006 | ||||||||
| LastUpdateDate: | 02/06/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 013652 | CT | Y | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.