Provider Demographics
NPI:1982681367
Name:JACCOMA, EDWARD H (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:H
Last Name:JACCOMA
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 1:87 GRANDVIEW AVE STE A
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2523
Mailing Address - Country:US
Mailing Address - Phone:203-574-2020
Mailing Address - Fax:203-596-2230
Practice Address - Street 1:87 GRANDVIEW AVE STE A
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2523
Practice Address - Country:US
Practice Address - Phone:203-574-2020
Practice Address - Fax:203-596-2230
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT56003207W00000X
ME011998207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME134050099Medicaid
CT1982681367Medicaid