Provider Demographics
NPI:1740234178
Name:FOTOVAT, AHMAD (MD)
Entity Type:Individual
Prefix:
First Name:AHMAD
Middle Name:
Last Name:FOTOVAT
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 1:115 TECHNOLOGY DR
Mailing Address - Street 2:C-100
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-6337
Mailing Address - Country:US
Mailing Address - Phone:203-268-5212
Mailing Address - Fax:203-268-6779
Practice Address - Street 1:115 TECHNOLOGY DR
Practice Address - Street 2:C-100
Practice Address - City:TRUMBULL
Practice Address - State:CT
Practice Address - Zip Code:06611-1395
Practice Address - Country:US
Practice Address - Phone:203-268-5212
Practice Address - Fax:203-268-6779
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT022045208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4395958OtherCIGNA
CT512H41OtherEMPIRE BC/BS
CT1176502OtherAETNA - HMO
CT2V5317OtherHEALTH NET
CT796029OtherCONNECTICARE
CT4662047OtherAETNA - PPO
CT010022045CT04OtherANTHEM BC/BS
CT103685OtherBETTER HEALTH ADVANTAGE
CTZS080OtherOXFORD HEALTH PLANS
CT512H41OtherEMPIRE BC/BS
CT103685OtherBETTER HEALTH ADVANTAGE