Provider Demographics
NPI:1043477045
Name:VASECTOMY CENTER OF CONNECTICUT, LLC
Entity Type:Organization
Organization Name:VASECTOMY CENTER OF CONNECTICUT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:MATSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-430-5773
Mailing Address - Street 1:PO BOX 10
Mailing Address - Street 2:
Mailing Address - City:EAST GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06025-0010
Mailing Address - Country:US
Mailing Address - Phone:860-430-5773
Mailing Address - Fax:860-430-5773
Practice Address - Street 1:2800 TAMARACK RD
Practice Address - Street 2:SUITE 108
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-5539
Practice Address - Country:US
Practice Address - Phone:860-430-5773
Practice Address - Fax:860-430-5773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-19
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT040285208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT7190376OtherAETNA
CT8711289OtherCIGNA
CT001402859Medicaid
CT040285OtherCONNECTICARE
CT001402859Medicaid