Provider Demographics
NPI:1447208632
Name:WAND, MARTIN (MD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:WAND
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 1:499 FARMINGTON AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-1943
Mailing Address - Country:US
Mailing Address - Phone:860-678-0202
Mailing Address - Fax:860-678-0224
Practice Address - Street 1:499 FARMINGTON AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-1943
Practice Address - Country:US
Practice Address - Phone:860-678-0202
Practice Address - Fax:860-678-0224
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT017514207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001175140Medicaid
180027295OtherRAILROAD MEDICARE
1619920592Medicare NSC
180000194Medicare PIN
180027295OtherRAILROAD MEDICARE
CT0714730002Medicare NSC
CTE10625Medicare UPIN
CT0714730001Medicare NSC