Basic Information
| Provider Information | |||||||||
| NPI: | 1760604961 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EASTERN CONNECTICUT DERMATOLOGY PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 491 GOLD STAR HWY | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | GROTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063406226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604458020 | ||||||||
| FaxNumber: | 8604451665 | ||||||||
| Practice Location | |||||||||
| Address1: | 491 GOLD STAR HWY | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | GROTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063406226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604458020 | ||||||||
| FaxNumber: | 8604451665 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2007 | ||||||||
| LastUpdateDate: | 11/25/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DAVIDSON | ||||||||
| AuthorizedOfficialFirstName: | DIANE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8604458020 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 025536 | CT | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 001255363 | 05 | CT | MEDICAID | 001233204 | 05 | CT | MEDICAID |