Provider Demographics
NPI:1477097285
Name:OEC WATERBURY LLC
Entity Type:Organization
Organization Name:OEC WATERBURY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:BONNANZIO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:203-377-3937
Mailing Address - Street 1:7365 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06614-1300
Mailing Address - Country:US
Mailing Address - Phone:203-377-3937
Mailing Address - Fax:888-741-0620
Practice Address - Street 1:3528 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06705-3873
Practice Address - Country:US
Practice Address - Phone:203-377-3934
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ORONOQUE EYE CARE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-12-13
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002346152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004160983Medicaid
CT004160983Medicaid