Provider Demographics
NPI:1487684346
Name:CONNECTICUT FOOT SPECIALISTS, P.C.
Entity Type:Organization
Organization Name:CONNECTICUT FOOT SPECIALISTS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:860-470-5703
Mailing Address - Street 1:11 SOUTH RD LOWR LEVEL20
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-2483
Mailing Address - Country:US
Mailing Address - Phone:860-470-5703
Mailing Address - Fax:860-909-0506
Practice Address - Street 1:11 SOUTH RD LOWR LEVEL20
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-2483
Practice Address - Country:US
Practice Address - Phone:860-470-5703
Practice Address - Fax:860-909-0506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000144213E00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTV00867Medicare UPIN
CTC02583Medicare ID - Type UnspecifiedGROUP NUMBER
CT480000974Medicare ID - Type UnspecifiedDR. WAGNER INDIVIDUAL NUM
CT0869800003Medicare NSC
CT480000178Medicare ID - Type UnspecifiedDR POLLACK INDIVIDUAL NUM
0869800001Medicare NSC
CTT22392Medicare UPIN
CT0869800002Medicare NSC