Provider Demographics
NPI:1255483269
Name:WETMORE, NEAL JOHNSON (LO)
Entity Type:Individual
Prefix:MR
First Name:NEAL
Middle Name:JOHNSON
Last Name:WETMORE
Suffix:
Gender:M
Credentials:LO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 WELLES ST
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-2047
Mailing Address - Country:US
Mailing Address - Phone:860-633-1401
Mailing Address - Fax:860-633-1401
Practice Address - Street 1:33 WELLES ST
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-2047
Practice Address - Country:US
Practice Address - Phone:860-633-1401
Practice Address - Fax:860-633-1401
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1047156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician