Provider Demographics
NPI:1437186251
Name:PETASHNICK, DANIEL E (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:E
Last Name:PETASHNICK
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 1:732 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-5106
Mailing Address - Country:US
Mailing Address - Phone:860-649-5177
Mailing Address - Fax:860-664-3490
Practice Address - Street 1:732 MAIN ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-5106
Practice Address - Country:US
Practice Address - Phone:860-649-5177
Practice Address - Fax:860-664-3490
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT035638207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1437186251Medicaid
CT001356387Medicaid