Provider Demographics
NPI:1861834210
Name:PETER GIACOMAZZI, MD,LLC
Entity Type:Organization
Organization Name:PETER GIACOMAZZI, MD,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:GIACOMAZZI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-879-8003
Mailing Address - Street 1:503 WOLCOTT RD
Mailing Address - Street 2:
Mailing Address - City:WOLCOTT
Mailing Address - State:CT
Mailing Address - Zip Code:06716-2673
Mailing Address - Country:US
Mailing Address - Phone:203-879-8003
Mailing Address - Fax:203-879-8010
Practice Address - Street 1:503 WOLCOTT RD
Practice Address - Street 2:
Practice Address - City:WOLCOTT
Practice Address - State:CT
Practice Address - Zip Code:06716-2673
Practice Address - Country:US
Practice Address - Phone:203-879-8003
Practice Address - Fax:203-879-8010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-26
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT419853207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001419531Medicaid