Provider Demographics
NPI:1790754901
Name:IMONDI, DAVID MICHAEL (OD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:MICHAEL
Last Name:IMONDI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 BOURBON STREET
Mailing Address - Street 2:
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074
Mailing Address - Country:US
Mailing Address - Phone:860-539-0584
Mailing Address - Fax:860-652-3291
Practice Address - Street 1:VA MEDICAL CENTER
Practice Address - Street 2:555 WILLARD AVENUE
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111
Practice Address - Country:US
Practice Address - Phone:860-667-6742
Practice Address - Fax:860-667-6833
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002297152W00000X
CT02297152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4118833Medicaid
CT410000573Medicare PIN
CT4118833Medicaid