Provider Demographics
NPI:1760440820
Name:PAYNE, JOHN L (PT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:L
Last Name:PAYNE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHESHIRE
Mailing Address - State:CT
Mailing Address - Zip Code:06410-3164
Mailing Address - Country:US
Mailing Address - Phone:203-271-2928
Mailing Address - Fax:203-699-8445
Practice Address - Street 1:475 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CHESHIRE
Practice Address - State:CT
Practice Address - Zip Code:06410-3164
Practice Address - Country:US
Practice Address - Phone:203-271-2928
Practice Address - Fax:203-699-8445
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002770225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT08-0002770CT01OtherANTHEM BC/BS
CT004082202Medicaid
CT508878OtherAETNA
CTCD8409OtherRR MEDICARE