Basic Information
| Provider Information | |||||||||
| NPI: | 1811292675 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CONNECTICUT FOOT AND ANKLE ASSOCIATES, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 245 AMITY RD | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | WOODBRIDGE | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065252258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2039366677 | ||||||||
| FaxNumber: | 2037743594 | ||||||||
| Practice Location | |||||||||
| Address1: | 245 AMITY RD | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | WOODBRIDGE | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065252258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2039366677 | ||||||||
| FaxNumber: | 2037743594 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2011 | ||||||||
| LastUpdateDate: | 05/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | KEY | ||||||||
| AuthorizedOfficialFirstName: | JONATHAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER | ||||||||
| AuthorizedOfficialTelephone: | 2039366677 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
| NPICertificationDate: | 05/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | 000781 | CT | N | Suppliers | Durable Medical Equipment & Medical Supplies | 213ES0103X | 000781 | CT | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 008034121 | 05 | CT | MEDICAID |