Provider Demographics
NPI:1568594554
Name:TRUMBULL MEDICAL PRACTICE
Entity Type:Organization
Organization Name:TRUMBULL MEDICAL PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:FLORES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-268-4884
Mailing Address - Street 1:115 TECHNOLOGY DR
Mailing Address - Street 2:A303
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-6337
Mailing Address - Country:US
Mailing Address - Phone:203-268-4884
Mailing Address - Fax:203-268-9371
Practice Address - Street 1:115 TECHNOLOGY DR
Practice Address - Street 2:A303
Practice Address - City:TRUMBULL
Practice Address - State:CT
Practice Address - Zip Code:06611-6337
Practice Address - Country:US
Practice Address - Phone:203-268-4884
Practice Address - Fax:203-268-9371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT038698207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010038698CT01OtherBCBS
CTOV7401OtherHEALTHNET
1541597OtherCIGNA
CT2338437OtherAETNA
CT00138698111Medicaid
CT745874OtherCONNECTICARE
CT010038698CT01OtherBCBS