Provider Demographics
NPI:1629040100
Name:ADAMENKO, ROBERT S (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:S
Last Name:ADAMENKO
Suffix:
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 1:290 WESTERN BLVD
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-1236
Mailing Address - Country:US
Mailing Address - Phone:860-633-9235
Mailing Address - Fax:
Practice Address - Street 1:320 WESTERN BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-1259
Practice Address - Country:US
Practice Address - Phone:860-633-9235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT038613208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001386136Medicaid
CT370001505Medicare ID - Type Unspecified
CT001386136Medicaid