Provider Demographics
NPI:1346338837
Name:DITEODORO, JACK V (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:V
Last Name:DITEODORO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:90 MORGAN ST
Mailing Address - Street 2:SUTIE # 303
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-5466
Mailing Address - Country:US
Mailing Address - Phone:203-323-6873
Mailing Address - Fax:203-358-9775
Practice Address - Street 1:90 MORGAN ST
Practice Address - Street 2:SUTIE # 303
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-5466
Practice Address - Country:US
Practice Address - Phone:203-323-6873
Practice Address - Fax:203-358-9775
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2010-10-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT035558208D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001355587Medicaid
CT1700194636OtherNPI
CT080001474Medicare ID - Type Unspecified
CT001355587Medicaid