Basic Information
Provider Information | |||||||||
NPI: | 1396714507 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WASSER | ||||||||
FirstName: | JEFFREY | ||||||||
MiddleName: | S | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 37 SASS DRIVE | ||||||||
Address2: |   | ||||||||
City: | MANCHESTER | ||||||||
State: | CT | ||||||||
PostalCode: | 060422243 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8607164260 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 263 FARMINGTON AVE | ||||||||
Address2: | UCONN CANCER CENTER | ||||||||
City: | FARMINGTON | ||||||||
State: | CT | ||||||||
PostalCode: | 060302875 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8606792100 | ||||||||
FaxNumber: | 8606794815 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/17/2006 | ||||||||
LastUpdateDate: | 05/26/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 021052 | CT | N |   | Other Service Providers | Specialist |   | 207RH0003X | 021052 | CT | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
ID | Type | State | Issuer | Description | 001210525 | 05 | CT |   | MEDICAID |