Provider Demographics
NPI:1679506836
Name:BACAY, ANGELITO C (MD)
Entity Type:Individual
Prefix:
First Name:ANGELITO
Middle Name:C
Last Name:BACAY
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 1:300 BIRCH MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-6800
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:281 HARTFORD TPKE
Practice Address - Street 2:SUITE 210
Practice Address - City:VERNON
Practice Address - State:CT
Practice Address - Zip Code:06066-4784
Practice Address - Country:US
Practice Address - Phone:860-872-8563
Practice Address - Fax:860-870-4857
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT029990174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT029990OtherSTATE LICENSE
CTE04347Medicare UPIN