Provider Demographics
NPI:1669635645
Name:ENCISO CHAVES, CARLOS ALBERTO (MD)
Entity Type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:ALBERTO
Last Name:ENCISO CHAVES
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 1:675 TOWER AVE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06112-1273
Mailing Address - Country:US
Mailing Address - Phone:860-714-2750
Mailing Address - Fax:
Practice Address - Street 1:201 CHESTNUT HILL RD
Practice Address - Street 2:
Practice Address - City:STAFFORD SPRINGS
Practice Address - State:CT
Practice Address - Zip Code:06076-4005
Practice Address - Country:US
Practice Address - Phone:860-714-2750
Practice Address - Fax:860-714-8591
Is Sole Proprietor?:No
Enumeration Date:2008-07-09
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT494832084P0800X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
1669635645Medicare PIN