Provider Demographics
NPI:1285019661
Name:LINDBERG, JONATHAN
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:LINDBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 EAST ST
Mailing Address - Street 2:
Mailing Address - City:PLAINVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06062-2309
Mailing Address - Country:US
Mailing Address - Phone:860-793-9378
Mailing Address - Fax:860-793-2494
Practice Address - Street 1:28 EAST ST
Practice Address - Street 2:
Practice Address - City:PLAINVILLE
Practice Address - State:CT
Practice Address - Zip Code:06062-2309
Practice Address - Country:US
Practice Address - Phone:860-793-9378
Practice Address - Fax:860-793-9378
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-27
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT1106156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician