Provider Demographics
NPI:1063985323
Name:WATERTOWN MEDICAL ASSOCIATES, LLC
Entity type:Organization
Organization Name:WATERTOWN MEDICAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAXIMILIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMEZ-TROCHEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-274-2418
Mailing Address - Street 1:365 MAIN ST STE 201
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06795-2249
Mailing Address - Country:US
Mailing Address - Phone:860-274-2418
Mailing Address - Fax:860-274-2986
Practice Address - Street 1:365 MAIN ST STE 201
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:CT
Practice Address - Zip Code:06795-2249
Practice Address - Country:US
Practice Address - Phone:860-274-2418
Practice Address - Fax:860-274-2986
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-09
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT049979OtherCONNECTICARE
CT1154493OtherUSA
CTP4376817OtherOXFORD
CT5856125OtherCIGNA
CTP01040202OtherRAILROAD MEDICARE
CT05856125OtherGREAT WEST