Provider Demographics
NPI:1467527580
Name:CONNECTICUT NEURODEVELOPMENTAL SERVICES
Entity Type:Organization
Organization Name:CONNECTICUT NEURODEVELOPMENTAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALOK
Authorized Official - Middle Name:
Authorized Official - Last Name:BHARGAVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-755-3279
Mailing Address - Street 1:134 GRANDVIEW AVE
Mailing Address - Street 2:SUITE# 208
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2507
Mailing Address - Country:US
Mailing Address - Phone:203-755-3279
Mailing Address - Fax:203-755-3057
Practice Address - Street 1:134 GRANDVIEW AVE
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2507
Practice Address - Country:US
Practice Address - Phone:203-755-3279
Practice Address - Fax:203-755-3057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT030847208000000X, 2080P0008X, 2084N0402X
CT003467363LF0000X, 363LP0200X
CT004478363LF0000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child NeurologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2080P0008XAllopathic & Osteopathic PhysiciansPediatricsNeurodevelopmental DisabilitiesGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTE57916Medicare UPIN