Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NX0100X | Occupational Health | 554 | CT |
NPI | 1962405282 |
---|---|
Provider Name | Dr. Martin Desomma |
First Address | Waterbury, CT 06708-3022 |
Second Address | Waterbury, CT 06708-3022 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 31/05/2005 |
Last Update Date | 09/02/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
004069530 | (05) | CT |
050000554CT01 | ANTHEM BLUE CROSS BLUE SH (01) | CT |
T22607 | (02) | CT |