Provider Demographics
NPI:1720061427
Name:FRIEDMAN, ROBERT M (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:M
Last Name:FRIEDMAN
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 1:132 MANSFIELD AVE
Mailing Address - Street 2:STE 114
Mailing Address - City:WILLIMANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06226-2027
Mailing Address - Country:US
Mailing Address - Phone:860-456-2267
Mailing Address - Fax:860-456-2267
Practice Address - Street 1:132 MANSFIELD AVE
Practice Address - Street 2:STE 114
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-2027
Practice Address - Country:US
Practice Address - Phone:860-456-2267
Practice Address - Fax:860-456-2267
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT15231207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1152313Medicaid
B39627Medicare UPIN