Provider Demographics
NPI:1700871530
Name:IRWIN, RICHARD L (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:L
Last Name:IRWIN
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 1:5 KENNEDY DR
Mailing Address - Street 2:
Mailing Address - City:PUTNAM
Mailing Address - State:CT
Mailing Address - Zip Code:06260-1939
Mailing Address - Country:US
Mailing Address - Phone:860-928-0414
Mailing Address - Fax:860-928-2239
Practice Address - Street 1:5 KENNEDY DR
Practice Address - Street 2:
Practice Address - City:PUTNAM
Practice Address - State:CT
Practice Address - Zip Code:06260-1939
Practice Address - Country:US
Practice Address - Phone:860-928-0414
Practice Address - Fax:860-928-2239
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2012-11-14
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-04-04
Provider Licenses
StateLicense IDTaxonomies
CT051403207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9708057Medicaid
MAA32265Medicare ID - Type Unspecified
MAB68287Medicare UPIN