Provider Demographics
NPI:1770607509
Name:PESALE, ROBERT (DC)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:PESALE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2505 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06615-5839
Mailing Address - Country:US
Mailing Address - Phone:203-386-9100
Mailing Address - Fax:203-375-3963
Practice Address - Street 1:2505 MAIN ST
Practice Address - Street 2:STATIONHOUSE SQUARE-BUILDING 1
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06615-5839
Practice Address - Country:US
Practice Address - Phone:203-386-9100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT718111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD400000295Medicare PIN