Provider Demographics
NPI:1164446175
Name:MAMMONE, MARIE R (ND)
Entity Type:Individual
Prefix:DR
First Name:MARIE
Middle Name:R
Last Name:MAMMONE
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:274 SILAS DEANE HWY
Mailing Address - Street 2:
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-1732
Mailing Address - Country:US
Mailing Address - Phone:860-529-1200
Mailing Address - Fax:860-882-1935
Practice Address - Street 1:274 SILAS DEANE HWY
Practice Address - Street 2:
Practice Address - City:WETHERSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06109-1732
Practice Address - Country:US
Practice Address - Phone:860-529-1200
Practice Address - Fax:860-882-1935
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000212208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT212000OtherCT CARE
CT110000212CT01OtherANTHEM BC/BS