Provider Demographics
NPI:1467588343
Name:HARTFORD DERMATOLOGY ASSOCIATES PC
Entity Type:Organization
Organization Name:HARTFORD DERMATOLOGY ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANET
Authorized Official - Middle Name:L
Authorized Official - Last Name:WEISNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-523-1087
Mailing Address - Street 1:65 MEMORIAL RD
Mailing Address - Street 2:SUITE 450
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-2434
Mailing Address - Country:US
Mailing Address - Phone:860-523-1087
Mailing Address - Fax:860-523-1472
Practice Address - Street 1:65 MEMORIAL RD
Practice Address - Street 2:SUITE 450
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-2434
Practice Address - Country:US
Practice Address - Phone:860-523-1087
Practice Address - Fax:860-523-1472
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT031336207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004394277Medicaid
CTC00936Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER