Provider Demographics
NPI:1033114897
Name:WERDELL, PAUL J (OD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:J
Last Name:WERDELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:553 FARMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105-3048
Mailing Address - Country:US
Mailing Address - Phone:860-236-5831
Mailing Address - Fax:860-236-2966
Practice Address - Street 1:553 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-3048
Practice Address - Country:US
Practice Address - Phone:860-236-5831
Practice Address - Fax:860-236-2966
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT771152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4024287Medicaid
T22391Medicare UPIN