Provider Demographics
NPI:1144387838
Name:D'MELLO, SURESH CEC IL (MD)
Entity Type:Individual
Prefix:
First Name:SURESH
Middle Name:CEC IL
Last Name:D'MELLO
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 1:19 HALLS RD
Mailing Address - Street 2:
Mailing Address - City:OLD LYME
Mailing Address - State:CT
Mailing Address - Zip Code:06371-1457
Mailing Address - Country:US
Mailing Address - Phone:860-434-8300
Mailing Address - Fax:
Practice Address - Street 1:19 HALLS RD
Practice Address - Street 2:
Practice Address - City:OLD LYME
Practice Address - State:CT
Practice Address - Zip Code:06371-1457
Practice Address - Country:US
Practice Address - Phone:860-434-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2009-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT033565207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001335654Medicaid
F80786Medicare UPIN
CT080000825Medicare ID - Type Unspecified