Provider Demographics
NPI:1356314959
Name:ROST, DWIGHT M (MD)
Entity Type:Individual
Prefix:DR
First Name:DWIGHT
Middle Name:M
Last Name:ROST
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 1:134 GRANDVIEW AVE
Mailing Address - Street 2:SUITE 108
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2507
Mailing Address - Country:US
Mailing Address - Phone:203-572-7266
Mailing Address - Fax:
Practice Address - Street 1:134 GRANDVIEW AVE
Practice Address - Street 2:SUITE 108
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2507
Practice Address - Country:US
Practice Address - Phone:203-572-7266
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT15732207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E47479Medicare UPIN