Provider Demographics
NPI:1164835153
Name:FARMINGTON VALLEY DERMATOLOGY AND SURGERY, LLC
Entity Type:Organization
Organization Name:FARMINGTON VALLEY DERMATOLOGY AND SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SADAF
Authorized Official - Middle Name:
Authorized Official - Last Name:WAQAR
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:860-674-9900
Mailing Address - Street 1:30 W AVON RD STE E
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-3678
Mailing Address - Country:US
Mailing Address - Phone:561-654-1789
Mailing Address - Fax:508-304-7532
Practice Address - Street 1:30 W AVON RD STE E
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-3678
Practice Address - Country:US
Practice Address - Phone:860-674-9900
Practice Address - Fax:860-678-0036
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-06
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT53002207N00000X
332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No332900000XSuppliersNon-Pharmacy Dispensing Site