Basic Information
| Provider Information | |||||||||
| NPI: | 1952491219 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BORGONOS | ||||||||
| FirstName: | OVANES | ||||||||
| MiddleName: | HALASAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 WASHINGTON SQ | ||||||||
| Address2: | |||||||||
| City: | NEW BRITAIN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060511848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602243642 | ||||||||
| FaxNumber: | 8602242760 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 WASHINGTON SQ | ||||||||
| Address2: | |||||||||
| City: | NEW BRITAIN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060511848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602243642 | ||||||||
| FaxNumber: | 8602242760 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2006 | ||||||||
| LastUpdateDate: | 08/03/2011 | ||||||||
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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 | 207Q00000X | 044410 | CT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 004236346 | 05 | CT | MEDICAID |