Provider Demographics
NPI:1407944689
Name:DIABETES AND ENDOCRINOLOGY OF NORTHWESTERN CONNECTICUT
Entity Type:Organization
Organization Name:DIABETES AND ENDOCRINOLOGY OF NORTHWESTERN CONNECTICUT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EGILS
Authorized Official - Middle Name:KNUTS
Authorized Official - Last Name:BOGDANOVICS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-496-2198
Mailing Address - Street 1:780 LITCHFIELD ST
Mailing Address - Street 2:
Mailing Address - City:TORRINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06790-6268
Mailing Address - Country:US
Mailing Address - Phone:860-496-2198
Mailing Address - Fax:860-489-2482
Practice Address - Street 1:780 LITCHFIELD ST
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790-6268
Practice Address - Country:US
Practice Address - Phone:860-496-2198
Practice Address - Fax:860-489-2482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT7133354OtherAETNA CLAIMS ID
CT4311104OtherAETNA EDI ID
CT3000OtherNEIC SITE ID, NSF BAO-7
CT001312660Medicaid
CT3000OtherNEIC SITE ID, NSF BAO-7
CT4311104OtherAETNA EDI ID
CT=========OtherTAX ID