Provider Demographics
NPI:1457316382
Name:FRESE, JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:FRESE
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 1:234A BANK ST
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-6054
Mailing Address - Country:US
Mailing Address - Phone:860-442-0290
Mailing Address - Fax:860-442-2136
Practice Address - Street 1:234A BANK ST
Practice Address - Street 2:4TH FLOOR
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-6054
Practice Address - Country:US
Practice Address - Phone:860-442-0290
Practice Address - Fax:860-442-2136
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT031797207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1317975Medicaid
CT010031797CT01OtherBLUECROSS
CT010031797CT01OtherBLUECROSS