Provider Demographics
NPI:1164576062
Name:DAM, MARIE (MD)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:DAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 TOWER LN
Mailing Address - Street 2:SUITE 103
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-4237
Mailing Address - Country:US
Mailing Address - Phone:860-921-3345
Mailing Address - Fax:860-201-1041
Practice Address - Street 1:35 TOWER LN
Practice Address - Street 2:SUITE 103
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-4237
Practice Address - Country:US
Practice Address - Phone:860-921-3345
Practice Address - Fax:860-201-1041
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT036441207R00000X
FL113731207R00000X
KY45523207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001364413Medicaid
E15611Medicare UPIN
CT001364413Medicaid