Basic Information
| Provider Information | |||||||||
| NPI: | 1336503382 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PROBASCO | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | VANDERVEER | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D., M.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 305 BLACK ROCK TPKE | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068255508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033372600 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 305 BLACK ROCK TPKE | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068255508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033372600 | ||||||||
| FaxNumber: | 2033372611 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2016 | ||||||||
| LastUpdateDate: | 10/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0004X | D91392 | MD | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery | 207XX0004X | 69667 | CT | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery |
No ID Information.