Provider Demographics
NPI:1912076886
Name:CONNECTICUT PODIATRY GROUP, P.C.
Entity Type:Organization
Organization Name:CONNECTICUT PODIATRY GROUP, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:DADDIO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:203-933-8606
Mailing Address - Street 1:385 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-4312
Mailing Address - Country:US
Mailing Address - Phone:203-933-8606
Mailing Address - Fax:203-932-9571
Practice Address - Street 1:385 MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-4312
Practice Address - Country:US
Practice Address - Phone:203-933-8606
Practice Address - Fax:203-932-9571
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTP00345213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0040608280Medicaid
CT0483650001Medicare NSC
480000377Medicare PIN
CTT22937Medicare UPIN