Provider Demographics
NPI:1457778193
Name:ADVANCED OPHTHALMOLOGY OF CONNECTICUT LLC
Entity Type:Organization
Organization Name:ADVANCED OPHTHALMOLOGY OF CONNECTICUT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:FUCIGNA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-348-7575
Mailing Address - Street 1:1455 EAST PUTNUM AVENUE
Mailing Address - Street 2:
Mailing Address - City:OLD GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06870
Mailing Address - Country:US
Mailing Address - Phone:203-348-7573
Mailing Address - Fax:203-348-2893
Practice Address - Street 1:1455 EAST PUTNAM AVENUE
Practice Address - Street 2:
Practice Address - City:OLD GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06870
Practice Address - Country:US
Practice Address - Phone:203-348-7573
Practice Address - Fax:203-348-2893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-19
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT35457207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTG10667Medicare UPIN