Provider Demographics
NPI:1265427983
Name:SQUILLACE, STEVEN RICHARD (OD)
Entity type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:RICHARD
Last Name:SQUILLACE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 801
Mailing Address - Street 2:
Mailing Address - City:SOMERS
Mailing Address - State:CT
Mailing Address - Zip Code:06071-1206
Mailing Address - Country:US
Mailing Address - Phone:860-763-4733
Mailing Address - Fax:
Practice Address - Street 1:48 SOUTH RD UNIT 8
Practice Address - Street 2:
Practice Address - City:SOMERS
Practice Address - State:CT
Practice Address - Zip Code:06071-2160
Practice Address - Country:US
Practice Address - Phone:860-763-4733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-19
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3270152WC0802X
CT2122152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0353418Medicaid
CT4243648Medicaid
CT410001030Medicare ID - Type Unspecified
CT4243648Medicaid