Provider Demographics
NPI:1780732289
Name:WILLIMAUTIC PEDIATRICS PC
Entity type:Organization
Organization Name:WILLIMAUTIC PEDIATRICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DAMARIS
Authorized Official - Middle Name:R
Authorized Official - Last Name:ORTIZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-456-1132
Mailing Address - Street 1:70 MANSFIELD AVENUE
Mailing Address - Street 2:
Mailing Address - City:WILLIMAUTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06226-2020
Mailing Address - Country:US
Mailing Address - Phone:860-456-1132
Mailing Address - Fax:860-456-2023
Practice Address - Street 1:70 MANSFIELD AVENUE
Practice Address - Street 2:
Practice Address - City:WILLIMAUTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-2020
Practice Address - Country:US
Practice Address - Phone:860-456-1132
Practice Address - Fax:860-456-2023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty