Provider Demographics
NPI:1568772242
Name:ANNETTE L HEADLEY MD LLC
Entity Type:Organization
Organization Name:ANNETTE L HEADLEY MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROPRIETOR/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:L
Authorized Official - Last Name:HEADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-536-1354
Mailing Address - Street 1:56 WHITEHALL AVE
Mailing Address - Street 2:
Mailing Address - City:MYSTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06355-1978
Mailing Address - Country:US
Mailing Address - Phone:860-536-1354
Mailing Address - Fax:860-536-7043
Practice Address - Street 1:56 WHITEHALL AVE
Practice Address - Street 2:
Practice Address - City:MYSTIC
Practice Address - State:CT
Practice Address - Zip Code:06355-1978
Practice Address - Country:US
Practice Address - Phone:860-536-1354
Practice Address - Fax:860-536-7043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-15
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT034245207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1295841682OtherPERSONAL NPI NUMBER