Basic Information
| Provider Information | |||||||||
| NPI: | 1275597882 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WASSERLAUF | ||||||||
| FirstName: | BRETT | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 35 JOLLEY DR | ||||||||
| Address2: | |||||||||
| City: | BLOOMFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060023062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602423000 | ||||||||
| FaxNumber: | 8602869547 | ||||||||
| Practice Location | |||||||||
| Address1: | 35 JOLLEY DR | ||||||||
| Address2: | |||||||||
| City: | BLOOMFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060023062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602423000 | ||||||||
| FaxNumber: | 8602869547 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2006 | ||||||||
| LastUpdateDate: | 07/18/2016 | ||||||||
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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 | 207XX0005X | 041794 | CT | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 001417949 | 05 | CT | MEDICAID |