Provider Demographics
NPI:1093816118
Name:DAVIGNON, MARC BERTRAND (MD)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:BERTRAND
Last Name:DAVIGNON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MARC
Other - Middle Name:B
Other - Last Name:DAVIGNON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD PC
Mailing Address - Street 1:111 FOUNDERS PLZ
Mailing Address - Street 2:SUITE 400
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-3212
Mailing Address - Country:US
Mailing Address - Phone:860-246-6589
Mailing Address - Fax:860-528-0778
Practice Address - Street 1:111 FOUNDERS PLZ
Practice Address - Street 2:SUITE 400
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06108-3212
Practice Address - Country:US
Practice Address - Phone:860-246-6589
Practice Address - Fax:860-528-0778
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT022073207U00000X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Not Answered2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4097392Medicaid
CT4097392Medicaid