Provider Demographics
NPI:1811964257
Name:HOLLECK, JURGEN LUDWIG (MD)
Entity type:Individual
Prefix:
First Name:JURGEN
Middle Name:LUDWIG
Last Name:HOLLECK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 CAMPBELL AVE
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-2770
Mailing Address - Country:US
Mailing Address - Phone:203-932-5711
Mailing Address - Fax:
Practice Address - Street 1:950 CAMPBELL AVE
Practice Address - Street 2:VACT HEALTHCARE
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516
Practice Address - Country:US
Practice Address - Phone:203-932-5711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT040023207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001400233Medicaid
CTH57253Medicare UPIN
CT001400233Medicaid