Provider Demographics
NPI:1700194636
Name:JACK V. DITEODORO M.D,LLC
Entity Type:Organization
Organization Name:JACK V. DITEODORO M.D,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:V
Authorized Official - Last Name:DITEODORO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-323-6873
Mailing Address - Street 1:90 MORGAN ST STE 303
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-5436
Mailing Address - Country:US
Mailing Address - Phone:203-323-6873
Mailing Address - Fax:
Practice Address - Street 1:90 MORGAN STEET STUITE 303
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-5436
Practice Address - Country:US
Practice Address - Phone:203-323-6873
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-14
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT035558302F00000X, 302R00000X, 305R00000X, 305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
No302F00000XManaged Care OrganizationsExclusive Provider Organization
No302R00000XManaged Care OrganizationsHealth Maintenance Organization
No305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001355587Medicaid
CT001355587Medicaid