Provider Demographics
NPI:1720281496
Name:BRIAN P. DESCHAMPS, DPM
Entity Type:Organization
Organization Name:BRIAN P. DESCHAMPS, DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:DESCHAMPS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:860-875-7078
Mailing Address - Street 1:196 PARKWAY S
Mailing Address - Street 2:SUITE 304
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385-1234
Mailing Address - Country:US
Mailing Address - Phone:860-442-7027
Mailing Address - Fax:860-444-0074
Practice Address - Street 1:351 MERLINE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:VERNON
Practice Address - State:CT
Practice Address - Zip Code:06066-4040
Practice Address - Country:US
Practice Address - Phone:860-875-7078
Practice Address - Fax:860-875-8991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-08
Last Update Date:2012-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000504213E00000X, 213ES0103X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC02551Medicare PIN