Provider Demographics
NPI:1952322711
Name:GOTTFRIED, DENNIS JAY (MD)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:JAY
Last Name:GOTTFRIED
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:895 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TORRINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06790-3918
Mailing Address - Country:US
Mailing Address - Phone:860-489-1291
Mailing Address - Fax:860-489-1804
Practice Address - Street 1:895 E MAIN ST
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790-3918
Practice Address - Country:US
Practice Address - Phone:860-489-1291
Practice Address - Fax:860-489-1804
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT21448207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C011077OtherMEDICARE GROUP UPIN
CT004394904Medicaid
110000950Medicare ID - Type Unspecified
CT004394904Medicaid