Provider Demographics
NPI:1437353505
Name:GREATER BRIDGEPORT UROLOGY CENTER PC
Entity Type:Organization
Organization Name:GREATER BRIDGEPORT UROLOGY CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT GREATER BRIDGEPORT UROLOG
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:D
Authorized Official - Last Name:MULDOON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-254-1576
Mailing Address - Street 1:425 POST RD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06824
Mailing Address - Country:US
Mailing Address - Phone:203-254-1576
Mailing Address - Fax:203-254-1809
Practice Address - Street 1:425 POST RD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824
Practice Address - Country:US
Practice Address - Phone:203-254-1576
Practice Address - Fax:203-254-1809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4067815Medicaid