Provider Demographics
NPI:1417952110
Name:GOTAY, VICTOR M (MD)
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:M
Last Name:GOTAY
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 1:171 GRANDVIEW AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2517
Mailing Address - Country:US
Mailing Address - Phone:203-597-1002
Mailing Address - Fax:203-575-9846
Practice Address - Street 1:171 GRANDVIEW AVE
Practice Address - Street 2:STE 203
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2517
Practice Address - Country:US
Practice Address - Phone:203-597-1002
Practice Address - Fax:203-575-9846
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-17
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT018038207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1180389Medicaid
CT040000137Medicare ID - Type Unspecified
CTB38140Medicare UPIN