Provider Demographics
NPI:1508863226
Name:MONROE, JOHN JR (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:MONROE
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:575 MAIN ST 2ND FLOOR
Mailing Address - Street 2:ATTN: CREDENTIALING DEPARTMENT
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-2718
Mailing Address - Country:US
Mailing Address - Phone:860-347-6971
Mailing Address - Fax:
Practice Address - Street 1:1 SHAWS CV
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4902
Practice Address - Country:US
Practice Address - Phone:860-447-8304
Practice Address - Fax:860-443-8720
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT033009207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008010088Medicaid
CT080000766Medicare ID - Type Unspecified
F63739Medicare UPIN