Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1700X | Ocularist | 0315275000 | CT |
NPI | 1023134665 |
---|---|
Provider Name | Mr. Louis John Marino |
First Address | Wallingford, CT 06492-3656 |
Second Address | Wallingford, CT 06492-3656 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/03/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
004092201 | (05) | CT |
12DME0303CT01 | ANTHEM BLUE CROSS AND BLU (01) | CT |