Basic Information
| Provider Information | |||||||||
| NPI: | 1225134208 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EMMEL | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | KEITH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2110 SILAS DEANE HWY | ||||||||
| Address2: | |||||||||
| City: | ROCKY HILL | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060672353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602583480 | ||||||||
| FaxNumber: | 8605716800 | ||||||||
| Practice Location | |||||||||
| Address1: | 1260 SILAS DEANE HWY | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | WETHERSFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061094362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8607218960 | ||||||||
| FaxNumber: | 8605632030 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 02/02/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 24341 | CT | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 052156 | 01 | CT | HEALTHNET | OTHER | 0243410 | 01 | CT | CONNECTICARE | OTHER | 0811678 | 01 | CT | AETNA | OTHER | 010024341CT01 | 01 | CT | BLUE CROSS | OTHER | P2043695 | 01 | CT | OXFORD | OTHER | 001243419 | 05 | CT | MEDICAID |