Provider Demographics
NPI:1558310763
Name:OUELLETTE, ROBERT J JR (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:J
Last Name:OUELLETTE
Suffix:JR
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 1:156 FARMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010-4218
Mailing Address - Country:US
Mailing Address - Phone:860-583-2108
Mailing Address - Fax:860-583-5487
Practice Address - Street 1:156 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-4218
Practice Address - Country:US
Practice Address - Phone:860-583-2108
Practice Address - Fax:860-583-5487
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT025570174400000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1255702Medicaid
CTD02730Medicare UPIN