Provider Demographics
NPI:1033311915
Name:GOLD STAR PEDIATRICS LLC
Entity Type:Organization
Organization Name:GOLD STAR PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BLEFELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-449-8882
Mailing Address - Street 1:495 GOLD STAR HWY
Mailing Address - Street 2:STE 120
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-6228
Mailing Address - Country:US
Mailing Address - Phone:860-449-8882
Mailing Address - Fax:860-449-9195
Practice Address - Street 1:495 GOLD STAR HWY
Practice Address - Street 2:STE 495
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-6228
Practice Address - Country:US
Practice Address - Phone:860-449-8882
Practice Address - Fax:860-449-9195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2008-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT22070208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004395530Medicaid
CT004238227Medicaid