Provider Demographics
NPI:1275506214
Name:LEVENTHAL, ROBERT I (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:I
Last Name:LEVENTHAL
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 1:166 WATERBURY RD
Mailing Address - Street 2:STE 104
Mailing Address - City:PROSPECT
Mailing Address - State:CT
Mailing Address - Zip Code:06712-1246
Mailing Address - Country:US
Mailing Address - Phone:203-756-6422
Mailing Address - Fax:203-756-2448
Practice Address - Street 1:1312 W MAIN ST
Practice Address - Street 2:STE 101
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708
Practice Address - Country:US
Practice Address - Phone:203-756-6422
Practice Address - Fax:203-756-2448
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT029930207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001299305Medicaid
100000242Medicare ID - Type Unspecified
CT001299305Medicaid