Provider Demographics
NPI:1982639241
Name:MARESH, HENRY RANDALL (MD)
Entity Type:Individual
Prefix:DR
First Name:HENRY
Middle Name:RANDALL
Last Name:MARESH
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 1:2 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032
Mailing Address - Country:US
Mailing Address - Phone:860-677-2017
Mailing Address - Fax:860-674-0878
Practice Address - Street 1:2 HIGH ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032
Practice Address - Country:US
Practice Address - Phone:860-677-2017
Practice Address - Fax:860-674-0878
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT017150207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
017150OtherCONNECTICARE
P601065OtherOXFORD
060986657001OtherCIGNA
010017150CT01OtherANTHEM
OV4711OtherHEALTHNET
017150OtherCONNECTICARE