Provider Demographics
NPI:1720404585
Name:MAMMONE, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:MAMMONE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:274 SILAS DEANE HWY
Mailing Address - Street 2:
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-1732
Mailing Address - Country:US
Mailing Address - Phone:860-529-1200
Mailing Address - Fax:860-882-1935
Practice Address - Street 1:274 SILAS DEANE HWY
Practice Address - Street 2:
Practice Address - City:WETHERSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06109-1732
Practice Address - Country:US
Practice Address - Phone:860-529-1200
Practice Address - Fax:860-882-1935
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-17
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000152171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist