Basic Information
| Provider Information | |||||||||
| NPI: | 1881623288 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLODNER | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | MYRUS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 56 FRANKLIN ST | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067061221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037096000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 56 FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067061253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037096000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 11/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | 039369 | CT | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | 039369 | CT | N | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RS0012X | 039369 | CT | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine |
ID Information
| ID | Type | State | Issuer | Description | 001393694 | 05 | CT | MEDICAID | 010039369CT03 | 01 | CT | ANTHEM BCBS CT | OTHER | 136130 | 01 | CT | WELLCARE | OTHER | 3781279/5069527 | 01 | CT | AETNA | OTHER | 1169235 | 01 | CT | USA | OTHER |