Provider Demographics
NPI:1659332807
Name:LOMOTAN, EDWIN A (MD)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:A
Last Name:LOMOTAN
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 1:2200 WHITNEY AVE
Mailing Address - Street 2:SUTIE 240
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06518-3691
Mailing Address - Country:US
Mailing Address - Phone:203-287-5400
Mailing Address - Fax:
Practice Address - Street 1:2200 WHITNEY AVE
Practice Address - Street 2:SUTIE 240
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-3691
Practice Address - Country:US
Practice Address - Phone:203-287-5400
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0424442080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT00142444900OtherBLUECARE FAMILY PLAN
CT0100422444CT01OtherANTHEM BLUE CROSS
CT2V7398OtherHEALTHNET
CT042444OtherCONNECTICARE
CTP3626837OtherOXFORD