Provider Demographics
NPI:1245744846
Name:TDG CONNECTICUT PLLC
Entity Type:Organization
Organization Name:TDG CONNECTICUT PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SIMON
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMAHA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-571-2121
Mailing Address - Street 1:347 MOUNT PLEASANT AVE STE 205
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-2749
Mailing Address - Country:US
Mailing Address - Phone:973-571-2121
Mailing Address - Fax:973-498-0512
Practice Address - Street 1:134 PARK ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-5409
Practice Address - Country:US
Practice Address - Phone:973-571-2121
Practice Address - Fax:973-498-0512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-20
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty