Provider Demographics
NPI:1639822125
Name:WALLINGFORD MEDICAL ASSOCIATES LLC
Entity Type:Organization
Organization Name:WALLINGFORD MEDICAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUANITA
Authorized Official - Middle Name:H
Authorized Official - Last Name:DEE
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:860-798-2614
Mailing Address - Street 1:150 EPISCOPAL RD
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:CT
Mailing Address - Zip Code:06037-1525
Mailing Address - Country:US
Mailing Address - Phone:860-798-2614
Mailing Address - Fax:860-467-4612
Practice Address - Street 1:850 N MAIN STREET EXT UNIT 1D2
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-2400
Practice Address - Country:US
Practice Address - Phone:860-798-2614
Practice Address - Fax:860-467-4612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-03
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1669889820Medicaid
CT1609344480Medicaid