Provider Demographics
NPI:1982649836
Name:TIKHOMIROV, VADIM (MD)
Entity Type:Individual
Prefix:
First Name:VADIM
Middle Name:
Last Name:TIKHOMIROV
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 1:79 SAND PIT ROAD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810
Mailing Address - Country:US
Mailing Address - Phone:203-749-5700
Mailing Address - Fax:203-749-5718
Practice Address - Street 1:95 LOCUST AVE
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-6148
Practice Address - Country:US
Practice Address - Phone:203-797-7173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2009-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT037705207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTH00390Medicare UPIN