Provider Demographics
NPI:1760688402
Name:THE CONNECTICUT CENTER FOR FACIAL PLASTIC
Entity Type:Organization
Organization Name:THE CONNECTICUT CENTER FOR FACIAL PLASTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:STUPAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-248-8409
Mailing Address - Street 1:2200 WHITNEY AVE
Mailing Address - Street 2:SUITE 260
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06518-3691
Mailing Address - Country:US
Mailing Address - Phone:203-248-8409
Mailing Address - Fax:203-281-2905
Practice Address - Street 1:2200 WHITNEY AVE
Practice Address - Street 2:SUITE 260
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-3691
Practice Address - Country:US
Practice Address - Phone:203-248-8409
Practice Address - Fax:203-281-2905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT043483174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1932197852OtherNPI
CT1932197852OtherNPI