Provider Demographics
NPI:1447430467
Name:WATERBURY PODIATRY CONSULTANTS
Entity Type:Organization
Organization Name:WATERBURY PODIATRY CONSULTANTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR. / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:BERNBACH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:203-753-2048
Mailing Address - Street 1:171 GRANDVIEW AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2517
Mailing Address - Country:US
Mailing Address - Phone:203-753-2048
Mailing Address - Fax:203-753-5891
Practice Address - Street 1:171 GRANDVIEW AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2517
Practice Address - Country:US
Practice Address - Phone:203-753-2048
Practice Address - Fax:203-753-5891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-07
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000447213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT409031Medicaid
CTT23154Medicare UPIN
CT409031Medicaid