Provider Demographics
NPI:1811031610
Name:COUTURE, RAYMOND ARTHUR (#594 LICENSED DISPEN)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:ARTHUR
Last Name:COUTURE
Suffix:
Gender:M
Credentials:#594 LICENSED DISPEN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 FARMINGTON AVE
Mailing Address - Street 2:SUITE 16
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-2717
Mailing Address - Country:US
Mailing Address - Phone:860-232-7616
Mailing Address - Fax:413-572-1308
Practice Address - Street 1:1007 FARMINGTON AVENUE
Practice Address - Street 2:SUITE 16
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-2107
Practice Address - Country:US
Practice Address - Phone:860-232-7616
Practice Address - Fax:860-233-4565
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT594156FX1800X
MA1270156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004036968Medicaid
CT004036968Medicaid