Provider Demographics
NPI:1386658276
Name:ARDOLINO, ANTHONY JACK (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:JACK
Last Name:ARDOLINO
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 1:1007 FARMINGTON AVE
Mailing Address - Street 2:STE 9
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107
Mailing Address - Country:US
Mailing Address - Phone:860-586-7825
Mailing Address - Fax:860-586-7827
Practice Address - Street 1:1007 FARMINGTON AVE
Practice Address - Street 2:STE 9
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107
Practice Address - Country:US
Practice Address - Phone:860-586-7825
Practice Address - Fax:860-586-7827
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT023836207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B84637Medicare UPIN