Provider Demographics
NPI:1184784126
Name:CIARDELLA, ANTHONY DOMINICK (MD)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:DOMINICK
Last Name:CIARDELLA
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 1:360 14 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489
Mailing Address - Country:US
Mailing Address - Phone:860-621-6759
Mailing Address - Fax:860-621-0117
Practice Address - Street 1:360 14 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489
Practice Address - Country:US
Practice Address - Phone:860-621-6759
Practice Address - Fax:860-621-0117
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT024620207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001246206Medicaid
CT110001129Medicare PIN
CT001246206Medicaid