Provider Demographics
NPI:1720747504
Name:PRESTIGE MEDICAL CONCIERGE PLLC
Entity Type:Organization
Organization Name:PRESTIGE MEDICAL CONCIERGE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:OSAMA
Authorized Official - Middle Name:
Authorized Official - Last Name:KANDALAFT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:475-837-8701
Mailing Address - Street 1:25 STEVENS STREET
Mailing Address - Street 2:
Mailing Address - City:EAST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06512
Mailing Address - Country:US
Mailing Address - Phone:475-837-8701
Mailing Address - Fax:
Practice Address - Street 1:25 STEVENS STREET
Practice Address - Street 2:
Practice Address - City:EAST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06512
Practice Address - Country:US
Practice Address - Phone:475-837-8701
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-09
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT063900OtherSTATE LICENSE