Provider Demographics
NPI:1467025312
Name:DR. MARK DILORETO LLC
Entity type:Organization
Organization Name:DR. MARK DILORETO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:FRANCIS
Authorized Official - Last Name:DI LORETO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:860-833-8096
Mailing Address - Street 1:359 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KENSINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06037-2651
Mailing Address - Country:US
Mailing Address - Phone:860-829-1020
Mailing Address - Fax:
Practice Address - Street 1:359 MAIN ST
Practice Address - Street 2:
Practice Address - City:KENSINGTON
Practice Address - State:CT
Practice Address - Zip Code:06037-2651
Practice Address - Country:US
Practice Address - Phone:860-829-1020
Practice Address - Fax:860-828-5246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-19
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008035812Medicaid
CT008104802Medicaid