Provider Demographics
NPI:1356480578
Name:DIGESTIVE DISEASE ASSOCIATES, LLC
Entity Type:Organization
Organization Name:DIGESTIVE DISEASE ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:DUNBAR
Authorized Official - Last Name:ILLICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-481-0315
Mailing Address - Street 1:687 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-3612
Mailing Address - Country:US
Mailing Address - Phone:203-481-7050
Mailing Address - Fax:203-488-6945
Practice Address - Street 1:1224 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-3778
Practice Address - Country:US
Practice Address - Phone:203-481-0315
Practice Address - Fax:203-481-6788
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004070314Medicaid
CT004070314Medicaid