Provider Demographics
NPI:1386667574
Name:DRISCOLL, JON C (MD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:C
Last Name:DRISCOLL
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 1:863 N MAIN STREET EXT
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-2434
Mailing Address - Country:US
Mailing Address - Phone:203-265-3280
Mailing Address - Fax:203-741-6569
Practice Address - Street 1:863 N MAIN STREET EXT
Practice Address - Street 2:SUITE 200
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-2434
Practice Address - Country:US
Practice Address - Phone:203-265-3280
Practice Address - Fax:203-741-6575
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT039464207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001394642Medicaid
200000974Medicare ID - Type Unspecified
H17534Medicare UPIN
CT001394642Medicaid