Provider Demographics
NPI:1205833878
Name:PACKER, ANDREW J (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:J
Last Name:PACKER
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 1:191 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06042-3556
Mailing Address - Country:US
Mailing Address - Phone:860-646-7704
Mailing Address - Fax:860-647-7340
Practice Address - Street 1:191 MAIN ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06042-3556
Practice Address - Country:US
Practice Address - Phone:860-646-7704
Practice Address - Fax:860-647-7340
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT028936207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTB61446Medicare UPIN