Provider Demographics
NPI:1295749752
Name:WILLETT, JOHN M (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:WILLETT
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 1:1 LONG WHARF DR
Mailing Address - Street 2:SUITE 302
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-5991
Mailing Address - Country:US
Mailing Address - Phone:203-624-2689
Mailing Address - Fax:203-776-7741
Practice Address - Street 1:1 LONG WHARF DR
Practice Address - Street 2:SUITE 302
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-5991
Practice Address - Country:US
Practice Address - Phone:203-624-2689
Practice Address - Fax:203-776-7741
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2009-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT031736207Y00000X, 207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT040004571OtherRAILROAD MEDICARE PIN
CT001317363Medicaid
E98407Medicare UPIN
CT001317363Medicaid