Provider Demographics
NPI:1225014731
Name:FOXMAN, ETHAN B (MD)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:B
Last Name:FOXMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 FOUNDERS PLZ
Mailing Address - Street 2:SUITE 400
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-3212
Mailing Address - Country:US
Mailing Address - Phone:860-291-6554
Mailing Address - Fax:860-783-5733
Practice Address - Street 1:85 SEYMOUR ST
Practice Address - Street 2:SUITE 200
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-5501
Practice Address - Country:US
Practice Address - Phone:860-289-3375
Practice Address - Fax:860-560-2849
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2018-01-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA2137702085R0202X, 2085N0700X
CT0422242085N0700X
CT422242085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010042224CT06OtherANTHEM BC/BS
CTA2516306OtherOXFORD
CT001422245Medicaid
CT010042224CT06OtherANTHEM BC/BS
CT300003534Medicare ID - Type Unspecified