Provider Demographics
NPI:1033697859
Name:OLD OAK PRIMARY CARE, P.C.
Entity Type:Organization
Organization Name:OLD OAK PRIMARY CARE, P.C.
Other - Org Name:OLD OAK PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOFER
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:FORT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-533-9436
Mailing Address - Street 1:250 MAIN ST S UNIT G
Mailing Address - Street 2:
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488-2263
Mailing Address - Country:US
Mailing Address - Phone:203-533-9436
Mailing Address - Fax:989-419-3050
Practice Address - Street 1:250 MAIN ST S UNIT G
Practice Address - Street 2:
Practice Address - City:SOUTHBURY
Practice Address - State:CT
Practice Address - Zip Code:06488-2263
Practice Address - Country:US
Practice Address - Phone:203-533-9436
Practice Address - Fax:989-419-3050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-02
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT056411207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008073500Medicaid