Provider Demographics
NPI:1841271699
Name:GRODOFSKY, MARSHALL P (MD)
Entity type:Individual
Prefix:
First Name:MARSHALL
Middle Name:P
Last Name:GRODOFSKY
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 1:836 FARMINGTON AVENUE
Mailing Address - Street 2:SUITE 207
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06119
Mailing Address - Country:US
Mailing Address - Phone:860-232-9911
Mailing Address - Fax:860-233-5996
Practice Address - Street 1:836 FARMINGTON AVENUE
Practice Address - Street 2:SUITE 207
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06119
Practice Address - Country:US
Practice Address - Phone:860-232-9911
Practice Address - Fax:860-233-5996
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT027137207K00000X, 207KI0005X, 207KA0200X
CT271372080P0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207KI0005XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyClinical & Laboratory Immunology
No2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001271378Medicaid
0585739002OtherCIGNA
P1870457OtherOXFORD
CTOS2228Medicaid
CT00127137800Medicaid
010027137CT01OtherBLUE CROSS
020138OtherCONNECTICARE
216970OtherPREFERRED ONE
P1870457OtherOXFORD
CT001271378Medicaid