Provider Demographics
NPI:1588830699
Name:AVERSA, JOHN M JR (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:AVERSA
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 WHITNEY AVE STE 170
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06518-3694
Mailing Address - Country:US
Mailing Address - Phone:203-281-7000
Mailing Address - Fax:
Practice Address - Street 1:2200 WHITNEY AVE STE 170
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-3694
Practice Address - Country:US
Practice Address - Phone:203-281-7000
Practice Address - Fax:203-909-6782
Is Sole Proprietor?:No
Enumeration Date:2008-05-08
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT044105208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD400160543Medicare PIN