Provider Demographics
NPI:1518134428
Name:CONNECTICUT ALLERGY & ASTHMA ASSOC PC
Entity Type:Organization
Organization Name:CONNECTICUT ALLERGY & ASTHMA ASSOC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:B
Authorized Official - Last Name:GOLDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-371-6060
Mailing Address - Street 1:4641 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606
Mailing Address - Country:US
Mailing Address - Phone:203-371-6060
Mailing Address - Fax:203-371-1977
Practice Address - Street 1:4641 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606
Practice Address - Country:US
Practice Address - Phone:203-371-6060
Practice Address - Fax:203-371-1977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-09
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
020804207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1208040Medicaid
CT1208040Medicaid
CTC03941Medicare PIN