Provider Demographics
NPI:1760679054
Name:ENDOCRINOLOGY ASSCOCIATES OF SOUTHERN CT, LLC
Entity Type:Organization
Organization Name:ENDOCRINOLOGY ASSCOCIATES OF SOUTHERN CT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DUBEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-372-4636
Mailing Address - Street 1:3715 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-3618
Mailing Address - Country:US
Mailing Address - Phone:203-372-4636
Mailing Address - Fax:203-372-4188
Practice Address - Street 1:3715 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-3611
Practice Address - Country:US
Practice Address - Phone:203-372-4636
Practice Address - Fax:203-372-4188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-01
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT041464207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC03391Medicare PIN
CTH19426Medicare UPIN
CT460000092Medicare PIN