Provider Demographics
NPI:1437263357
Name:DEFRANCESCO, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:DEFRANCESCO
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 1:60 WESTWOOD AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708
Mailing Address - Country:US
Mailing Address - Phone:203-574-5501
Mailing Address - Fax:203-596-0912
Practice Address - Street 1:60 WESTWOOD AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708
Practice Address - Country:US
Practice Address - Phone:203-574-5501
Practice Address - Fax:203-596-0912
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT023375207VG0400X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001233758Medicaid
CT001233758Medicaid
160001553Medicare ID - Type Unspecified