Provider Demographics
NPI:1275627093
Name:DR. PHILIP A. MONGELLUZZO, JR. LLC
Entity Type:Organization
Organization Name:DR. PHILIP A. MONGELLUZZO, JR. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:A
Authorized Official - Last Name:MONGELLUZZO
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:203-757-3486
Mailing Address - Street 1:93 HEMPEL DRIVE
Mailing Address - Street 2:
Mailing Address - City:WOLCOTT
Mailing Address - State:CT
Mailing Address - Zip Code:06716
Mailing Address - Country:US
Mailing Address - Phone:203-757-3486
Mailing Address - Fax:
Practice Address - Street 1:2247 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06705
Practice Address - Country:US
Practice Address - Phone:203-757-3486
Practice Address - Fax:203-757-4376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004245272Medicaid
CT004245272Medicaid