Provider Demographics
NPI:1639245236
Name:EYE CENTER OF SOUTHERN CONNECTUCUT, PC
Entity Type:Organization
Organization Name:EYE CENTER OF SOUTHERN CONNECTUCUT, PC
Other - Org Name:EYE CENTER A MEDICAL SURGICAL GROUP
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:E
Authorized Official - Last Name:MASI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-248-6365
Mailing Address - Street 1:415 HIGHLAND AVENUE
Mailing Address - Street 2:
Mailing Address - City:CHESHIRE
Mailing Address - State:CT
Mailing Address - Zip Code:06410
Mailing Address - Country:US
Mailing Address - Phone:203-272-5494
Mailing Address - Fax:203-272-7637
Practice Address - Street 1:2880 OLD DIXWELL AVE
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518
Practice Address - Country:US
Practice Address - Phone:203-248-6365
Practice Address - Fax:203-281-2742
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004067435Medicaid
CT004067435Medicaid