Provider Demographics
NPI:1841292802
Name:OSTROM, HAL LAWRENCE (OD)
Entity type:Individual
Prefix:DR
First Name:HAL
Middle Name:LAWRENCE
Last Name:OSTROM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 E MAIN ST
Mailing Address - Street 2:UNIT 4
Mailing Address - City:CLINTON
Mailing Address - State:CT
Mailing Address - Zip Code:06413-2120
Mailing Address - Country:US
Mailing Address - Phone:860-669-2020
Mailing Address - Fax:
Practice Address - Street 1:116 E MAIN ST
Practice Address - Street 2:UNIT 4
Practice Address - City:CLINTON
Practice Address - State:CT
Practice Address - Zip Code:06413-2120
Practice Address - Country:US
Practice Address - Phone:860-669-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-02
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2017152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0900002017CT02OtherANTHEM
CT512366OtherAETNA
CT734485OtherCONNECTICARE
CT004130374Medicaid
CT0V0060OtherHEALTHNET
CTP384312OtherOXFORD
CT0900002017CT02OtherANTHEM
CT41000418Medicare PIN