Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207QA0401X | Family Doctor - Addiction Medicine | 011764 | ME |
Y | 207QA0401X | Family Doctor - Addiction Medicine | 049233 | CT |
NPI | 1043239783 |
---|---|
Provider Name | Thomas R Defanti |
First Address | North Stonington, CT 06359-1022 |
Second Address | North Stonington, CT 06359-1022 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/07/2006 |
Last Update Date | 30/04/2014 |