Provider Demographics
NPI:1639189533
Name:SIRACO, JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:SIRACO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:4 FARM SPRINGS RD
Mailing Address - Street 2:PROHEALTH PHYSICIANS
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-2573
Mailing Address - Country:US
Mailing Address - Phone:860-284-5200
Mailing Address - Fax:860-284-5333
Practice Address - Street 1:505 WILLARD AVE
Practice Address - Street 2:
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111-2650
Practice Address - Country:US
Practice Address - Phone:860-666-5601
Practice Address - Fax:860-667-3909
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT020105208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTG42434Medicare UPIN