Provider Demographics
NPI:1730103862
Name:DUA, VIPUL (MD)
Entity Type:Individual
Prefix:
First Name:VIPUL
Middle Name:
Last Name:DUA
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 1:2800 TAMARACK RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-5539
Mailing Address - Country:US
Mailing Address - Phone:860-644-5900
Mailing Address - Fax:860-644-5900
Practice Address - Street 1:2800 TAMARACK RD
Practice Address - Street 2:SUITE 106
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-5539
Practice Address - Country:US
Practice Address - Phone:860-644-5900
Practice Address - Fax:860-644-5900
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT041795207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001417957Medicaid
CT001417957Medicaid
CT200001040Medicare PIN