Provider Demographics
NPI:1255378501
Name:WATERBURY NEUROLOGY LLC
Entity type:Organization
Organization Name:WATERBURY NEUROLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:POOIA
Authorized Official - Middle Name:
Authorized Official - Last Name:FATTAHI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-758-8995
Mailing Address - Street 1:1625 STRAITS TURNPIKE
Mailing Address - Street 2:SUITE 307
Mailing Address - City:MIDDLEBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06762-1836
Mailing Address - Country:US
Mailing Address - Phone:203-758-8995
Mailing Address - Fax:203-758-2571
Practice Address - Street 1:1625 STRAITS TURNPIKE
Practice Address - Street 2:SUITE 307
Practice Address - City:MIDDLEBURY
Practice Address - State:CT
Practice Address - Zip Code:06762-1836
Practice Address - Country:US
Practice Address - Phone:203-758-8995
Practice Address - Fax:203-758-2571
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2084N0400X
CT0361132084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1284603Medicaid
CT1361138Medicaid
CT1361138Medicaid
CTG91574Medicare UPIN