Provider Demographics
NPI:1497784995
Name:WALTZMAN, MICHAEL N (MD, PHD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:N
Last Name:WALTZMAN
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:965 WHITE PLAINS RD
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-4566
Mailing Address - Country:US
Mailing Address - Phone:203-268-0228
Mailing Address - Fax:203-268-0378
Practice Address - Street 1:965 WHITE PLAINS RD
Practice Address - Street 2:3RD FLOOR
Practice Address - City:TRUMBULL
Practice Address - State:CT
Practice Address - Zip Code:06611-4566
Practice Address - Country:US
Practice Address - Phone:203-268-0228
Practice Address - Fax:203-268-0378
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2013-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT042069207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004245149Medicaid
CTD400000050Medicare PIN
CT004245149Medicaid
CTC03962Medicare PIN