Provider Demographics
NPI:1083658629
Name:ABBOTT, JAY L (MD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:L
Last Name:ABBOTT
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 1:130 NORFOLK RD
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06759-2515
Mailing Address - Country:US
Mailing Address - Phone:860-567-8848
Mailing Address - Fax:860-567-8848
Practice Address - Street 1:130 NORFOLK RD
Practice Address - Street 2:
Practice Address - City:LITCHFIELD
Practice Address - State:CT
Practice Address - Zip Code:06759-2515
Practice Address - Country:US
Practice Address - Phone:860-567-8848
Practice Address - Fax:860-567-8848
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME016526174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEB39563Medicare UPIN