Provider Demographics
NPI:1609985654
Name:JORGE DABDOUB MD INTERNAL MEDICINE LLC
Entity Type:Organization
Organization Name:JORGE DABDOUB MD INTERNAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:A
Authorized Official - Last Name:DABDOUB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-889-4476
Mailing Address - Street 1:12 CASE ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-2222
Mailing Address - Country:US
Mailing Address - Phone:860-889-4476
Mailing Address - Fax:860-889-6452
Practice Address - Street 1:12 CASE ST
Practice Address - Street 2:SUITE 104
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-2222
Practice Address - Country:US
Practice Address - Phone:860-889-4476
Practice Address - Fax:860-889-6452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT033578261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1335787Medicaid
CT110005591Medicare ID - Type Unspecified
CT1335787Medicaid