Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223G0001X | General Practice | 7680 | CT |
Y | 213EG0000X | General Practice | 7680 | CT |
NPI | 1003835893 |
---|---|
Provider Name | Dr. John R. Gagne |
First Address | Waterbury, CT 06708-4626 |
Second Address | Waterbury, CT 06708-4626 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/07/2006 |
Last Update Date | 08/07/2007 |