Provider Demographics
NPI:1760604961
Name:EASTERN CONNECTICUT DERMATOLOGY PC
Entity Type:Organization
Organization Name:EASTERN CONNECTICUT DERMATOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:M
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-445-8020
Mailing Address - Street 1:491 GOLD STAR HWY
Mailing Address - Street 2:SUITE 310
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-6226
Mailing Address - Country:US
Mailing Address - Phone:860-445-8020
Mailing Address - Fax:860-445-1665
Practice Address - Street 1:491 GOLD STAR HWY
Practice Address - Street 2:SUITE 310
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-6226
Practice Address - Country:US
Practice Address - Phone:860-445-8020
Practice Address - Fax:860-445-1665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2013-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT025536174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001255363Medicaid
CT001233204Medicaid
CT970000586Medicare ID - Type UnspecifiedSARAH OVERMOYER PA-C
CT001255363Medicaid
CTB83710Medicare UPIN
CTD95243Medicare UPIN
CT070000432Medicare ID - Type UnspecifiedDR. JEFFREY SHORNICK
CT001233204Medicaid