Basic Information
| Provider Information | |||||||||
| NPI: | 1487847570 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KENNETH J. MAIOCCO, M.D., P.C. | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4639 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066061838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033745546 | ||||||||
| FaxNumber: | 3023714056 | ||||||||
| Practice Location | |||||||||
| Address1: | 4639 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066061838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033745546 | ||||||||
| FaxNumber: | 3023714056 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2007 | ||||||||
| LastUpdateDate: | 08/22/2007 | ||||||||
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| AuthorizedOfficialLastName: | MAIOCCO | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | K. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2033745130 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 013652 | CT | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.