Provider Demographics
NPI:1114150984
Name:ANISIMOV, DANIL
Entity Type:Individual
Prefix:
First Name:DANIL
Middle Name:
Last Name:ANISIMOV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 RICHARDS GROVE RD
Mailing Address - Street 2:
Mailing Address - City:QUAKER HILL
Mailing Address - State:CT
Mailing Address - Zip Code:06375-1524
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 RESEARCH PKWY
Practice Address - Street 2:
Practice Address - City:OLD SAYBROOK
Practice Address - State:CT
Practice Address - Zip Code:06475-4214
Practice Address - Country:US
Practice Address - Phone:800-370-3651
Practice Address - Fax:860-510-0020
Is Sole Proprietor?:No
Enumeration Date:2009-08-27
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4165363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily