Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 34327 | CT |
Y | 207QA0401X | Family Doctor - Addiction Medicine | 034327 | CT |
NPI | 1902899859 |
---|---|
Provider Name | Ayaz T Madraswalla |
First Address | Windsor, CT 06095-1588 |
Second Address | Putnam, CT 06260-1852 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/08/2005 |
Last Update Date | 22/01/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
E95765 | (02) |