Provider Demographics
NPI:1710946678
Name:PASSALACQUA, JO-ANNE (MD)
Entity Type:Individual
Prefix:
First Name:JO-ANNE
Middle Name:
Last Name:PASSALACQUA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 BLACK ROCK TPKE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-3239
Mailing Address - Country:US
Mailing Address - Phone:203-384-0451
Mailing Address - Fax:203-384-0472
Practice Address - Street 1:2150 BLACK ROCK TPKE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825-3239
Practice Address - Country:US
Practice Address - Phone:203-384-0451
Practice Address - Fax:203-384-0472
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT035850207RI0200X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001358507Medicaid
CTG44874Medicare UPIN
CTD400134056Medicare PIN