Basic Information
| Provider Information | |||||||||
| NPI: | 1518248954 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VENTULETT | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | LOUIS | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 365 MONTAUK AVE | ||||||||
| Address2: | |||||||||
| City: | NEW LONDON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063204700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602714364 | ||||||||
| FaxNumber: | 8604445114 | ||||||||
| Practice Location | |||||||||
| Address1: | 365 MONTAUK AVE | ||||||||
| Address2: | |||||||||
| City: | NEW LONDON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063204700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602714364 | ||||||||
| FaxNumber: | 8604445114 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2011 | ||||||||
| LastUpdateDate: | 07/10/2013 | ||||||||
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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 | 363A00000X | 1680 | SC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 2933 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 1236PA | 05 | SC | MEDICAID | 1680 | 01 | SC | STATE LICENSE | OTHER |