Provider Demographics
NPI:1760878094
Name:DRISCOLL, JOHN JAY
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:JAY
Last Name:DRISCOLL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 STATE ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-6397
Mailing Address - Country:US
Mailing Address - Phone:860-444-1949
Mailing Address - Fax:
Practice Address - Street 1:165 STATE ST
Practice Address - Street 2:SUITE 100
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-6397
Practice Address - Country:US
Practice Address - Phone:860-444-1949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-14
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT034263224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist