Provider Demographics
NPI:1093800013
Name:SASONOV, MARINA
Entity Type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:SASONOV
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:580 FARMINGTON AVE
Mailing Address - Street 2:SUITE #101
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105-3050
Mailing Address - Country:US
Mailing Address - Phone:860-570-0800
Mailing Address - Fax:860-570-0666
Practice Address - Street 1:580 FARMINGTON AVE
Practice Address - Street 2:SUITE #101
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-3050
Practice Address - Country:US
Practice Address - Phone:860-570-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2009-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT650001385Medicare PIN