Provider Demographics
NPI:1528029634
Name:EYE CENTER OF SOUTHERN CONNECTICUT PC
Entity Type:Organization
Organization Name:EYE CENTER OF SOUTHERN CONNECTICUT PC
Other - Org Name:EYE CENTER A MEDICAL SURGICAL GROUP
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:E
Authorized Official - Last Name:MASI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-248-6365
Mailing Address - Street 1:2880 OLD DIXWELL AVENUE
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06518
Mailing Address - Country:US
Mailing Address - Phone:203-248-6365
Mailing Address - Fax:203-281-2742
Practice Address - Street 1:2880 OLD DIXWELL AVE
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-3144
Practice Address - Country:US
Practice Address - Phone:203-248-6365
Practice Address - Fax:203-281-2742
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-29
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004067435Medicaid
CT0674910001OtherPTAN
CTC14769Medicare PIN
CT004067435Medicaid