Provider Demographics
NPI:1497774657
Name:DETROJA, KISMATKUMAR (MD)
Entity Type:Individual
Prefix:
First Name:KISMATKUMAR
Middle Name:
Last Name:DETROJA
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 1:170 TALCOTT RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-2386
Mailing Address - Country:US
Mailing Address - Phone:860-794-9160
Mailing Address - Fax:
Practice Address - Street 1:1000 SILVER STREET
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457
Practice Address - Country:US
Practice Address - Phone:860-951-4954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT044462207R00000X
CT8 WINDWOOD DRIVE208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010044462CT01OtherBCBS
CT001444629Medicaid
CT144462OtherCONNECTICARE
CT1497774657OtherCHN
149777465OtherCIGNA
207787971OtherTRICARE
41044914OtherTRICARE
7382858OtherAETNA
CT581828OtherHMN
CT7382858OtherAETNA
CT1497774657OtherCIGNA
CT1497774657OtherCIGNA
207787971OtherTRICARE