Provider Demographics
NPI:1669577540
Name:FENTON, DAVID (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:FENTON
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:PO BOX 587
Mailing Address - Street 2:
Mailing Address - City:ROCKY HILL
Mailing Address - State:CT
Mailing Address - Zip Code:06067-0587
Mailing Address - Country:US
Mailing Address - Phone:860-258-3480
Mailing Address - Fax:860-571-6800
Practice Address - Street 1:100 RETREAT AVE
Practice Address - Street 2:SUITE 903
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-2528
Practice Address - Country:US
Practice Address - Phone:860-244-0148
Practice Address - Fax:860-240-7063
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT041531207R00000X
CT41531207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT06144079005Medicaid
CT06144079005Medicaid