Provider Demographics
NPI:1942414081
Name:TOWN AND COUNTRY PEDIATRICS AND FAMILY MEDICINE, P.C.
Entity Type:Organization
Organization Name:TOWN AND COUNTRY PEDIATRICS AND FAMILY MEDICINE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:O
Authorized Official - Last Name:LUSTIG
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:860-274-8891
Mailing Address - Street 1:380 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06795
Mailing Address - Country:US
Mailing Address - Phone:860-274-8891
Mailing Address - Fax:860-274-8895
Practice Address - Street 1:380 MAIN STREET
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:CT
Practice Address - Zip Code:06795
Practice Address - Country:US
Practice Address - Phone:860-274-8891
Practice Address - Fax:860-274-8895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT041948207Q00000X
CT035903208000000X
CT001457363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT080001803Medicare ID - Type Unspecified
CTH02184Medicare UPIN