Provider Demographics
NPI:1750357596
Name:GIFFAULT, GEORGE (DO)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:GIFFAULT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:365 MONTAUK AVE
Mailing Address - Street 2:ROOM 4.512
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-4700
Mailing Address - Country:US
Mailing Address - Phone:860-442-0711
Mailing Address - Fax:860-444-5114
Practice Address - Street 1:25 WELLS ST
Practice Address - Street 2:
Practice Address - City:WESTERLY
Practice Address - State:RI
Practice Address - Zip Code:02891-2922
Practice Address - Country:US
Practice Address - Phone:800-933-5960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT040038208M00000X, 207R00000X
RIDO00542207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
H66512Medicare UPIN
CT010000764Medicare ID - Type Unspecified