Provider Demographics
NPI:1013197722
Name:FREEDMAN, ELISSA LANE
Entity Type:Individual
Prefix:DR
First Name:ELISSA
Middle Name:LANE
Last Name:FREEDMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELISSA
Other - Middle Name:LANE
Other - Last Name:NEWSOME
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:23 LIBERTY DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:HEBRON
Mailing Address - State:CT
Mailing Address - Zip Code:06248-1553
Mailing Address - Country:US
Mailing Address - Phone:860-228-1119
Mailing Address - Fax:860-228-4314
Practice Address - Street 1:23 LIBERTY DR
Practice Address - Street 2:SUITE A
Practice Address - City:HEBRON
Practice Address - State:CT
Practice Address - Zip Code:06248-1553
Practice Address - Country:US
Practice Address - Phone:860-228-1119
Practice Address - Fax:860-228-4314
Is Sole Proprietor?:No
Enumeration Date:2007-11-09
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT050034207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004236164Medicaid
1013197722OtherNPI