Provider Demographics
NPI:1124026869
Name:PHILLIPS, HAROLD EUGENE JR (MD)
Entity Type:Individual
Prefix:DR
First Name:HAROLD
Middle Name:EUGENE
Last Name:PHILLIPS
Suffix:JR
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 1:3 HERON RD
Mailing Address - Street 2:
Mailing Address - City:MYSTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06355-3253
Mailing Address - Country:US
Mailing Address - Phone:860-536-6442
Mailing Address - Fax:860-536-6442
Practice Address - Street 1:3 HERON RD
Practice Address - Street 2:
Practice Address - City:MYSTIC
Practice Address - State:CT
Practice Address - Zip Code:06355-3253
Practice Address - Country:US
Practice Address - Phone:860-536-6442
Practice Address - Fax:860-536-6442
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME146710207Q00000X, 208M00000X
CT036959207QG0300X
CT36959207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001369596Medicaid
CT001369596Medicaid
080001823Medicare PIN