Provider Demographics
NPI:1689812885
Name:CONNECTICUT PLASTIC SURGERY GROUP, LLC
Entity Type:Organization
Organization Name:CONNECTICUT PLASTIC SURGERY GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:TITO
Authorized Official - Middle Name:L
Authorized Official - Last Name:VASQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-292-8119
Mailing Address - Street 1:2600 POST RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06890-1258
Mailing Address - Country:US
Mailing Address - Phone:203-292-8119
Mailing Address - Fax:203-292-8120
Practice Address - Street 1:2600 POST RD
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:CT
Practice Address - Zip Code:06890-1258
Practice Address - Country:US
Practice Address - Phone:203-292-8119
Practice Address - Fax:203-292-8120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-26
Last Update Date:2009-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0461692086S0105X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Multi-Specialty
No2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the HandGroup - Multi-Specialty