1336872233 NPI number — INTEGRATED DERMATOLOGY OF GLASTONBURY PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336872233 NPI number — INTEGRATED DERMATOLOGY OF GLASTONBURY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTEGRATED DERMATOLOGY OF GLASTONBURY PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336872233
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/07/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4700 EXCHANGE CT STE 110
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOCA RATON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33431-4450
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-314-2000
Provider Business Mailing Address Fax Number:
561-431-2821

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
622 HEBRON AVE STE 107
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLASTONBURY
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06033-5003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-657-3376
Provider Business Practice Location Address Fax Number:
860-633-6040
Provider Enumeration Date:
07/07/2022

Additional Information

Authorized Official

Authorized Official Last Name:
SINHA
Authorized Official First Name:
ANIMESH
Authorized Official Middle Name:
Authorized Official Title or Position:
AUTHORIZED GROUP OFFICIAL
Authorized Official Telephone Number:
561-314-2000

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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