Provider Demographics
NPI:1962405282
Name:DESOMMA, MARTIN (DC)
Entity type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:
Last Name:DESOMMA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:276 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-3022
Mailing Address - Country:US
Mailing Address - Phone:203-753-6384
Mailing Address - Fax:203-759-1705
Practice Address - Street 1:276 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-3022
Practice Address - Country:US
Practice Address - Phone:203-753-6384
Practice Address - Fax:203-759-1705
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-31
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT554111NX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0100XChiropractic ProvidersChiropractorOccupational Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004069530Medicaid
CT050000554CT01OtherANTHEM BLUE CROSS BLUE SH
CT350000353Medicare ID - Type Unspecified
CT050000554CT01OtherANTHEM BLUE CROSS BLUE SH