Provider Demographics
NPI:1114956380
Name:AFERZON, MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:AFERZON
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 1:225 ANSONIA ROAD
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:CT
Mailing Address - Zip Code:06525
Mailing Address - Country:US
Mailing Address - Phone:203-298-9295
Mailing Address - Fax:203-954-0018
Practice Address - Street 1:2 IVY BROOK RD
Practice Address - Street 2:SUITE 110
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484-6416
Practice Address - Country:US
Practice Address - Phone:203-954-0019
Practice Address - Fax:203-954-0018
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-01
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT040095207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001400952Medicaid
CT001400952Medicaid
CT040000362Medicare ID - Type UnspecifiedMEDICARE ID