Provider Demographics
NPI:1043239783
Name:DEFANTI, THOMAS R (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:R
Last Name:DEFANTI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 SWANTOWN HL
Mailing Address - Street 2:
Mailing Address - City:NORTH STONINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06359-1022
Mailing Address - Country:US
Mailing Address - Phone:860-535-1010
Mailing Address - Fax:860-445-3677
Practice Address - Street 1:75 SWANTOWN HL
Practice Address - Street 2:
Practice Address - City:NORTH STONINGTON
Practice Address - State:CT
Practice Address - Zip Code:06359-1022
Practice Address - Country:US
Practice Address - Phone:860-535-1010
Practice Address - Fax:860-445-3677
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT049233207QA0401X
ME011764207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine