Provider Demographics
NPI:1477536522
Name:MAROTTOLI, RICHARD A (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
Last Name:MAROTTOLI
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 1:20 YORK ST
Mailing Address - Street 2:DANA BUILDING, 3RD FLOOR
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-3220
Mailing Address - Country:US
Mailing Address - Phone:203-785-6361
Mailing Address - Fax:203-737-4209
Practice Address - Street 1:20 YORK ST
Practice Address - Street 2:DANA BUILDING, 3RD FLOOR
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3220
Practice Address - Country:US
Practice Address - Phone:203-785-6361
Practice Address - Fax:203-737-4209
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT028117207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001281170Medicaid
CT001281170Medicaid
CT110003551Medicare PIN