Basic Information
| Provider Information | |||||||||
| NPI: | 1649353350 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DELLERT | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 COLUMBUS BLVD FL 4 | ||||||||
| Address2: | |||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061061976 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8608375602 | ||||||||
| FaxNumber: | 8608375613 | ||||||||
| Practice Location | |||||||||
| Address1: | 11 SOUTH RD STE 120 | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060322483 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8608376350 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 04/02/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0008X | MA06455000 | NJ | N | Allopathic & Osteopathic Physicians | Pediatrics | Neurodevelopmental Disabilities | 2080P0008X | 31703 | CT | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neurodevelopmental Disabilities |
ID Information
| ID | Type | State | Issuer | Description | 7812205 | 05 | NJ | MEDICAID |