Provider Demographics
NPI:1104929702
Name:ITALIA, GARY R (DC)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:R
Last Name:ITALIA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 15
Mailing Address - Street 2:
Mailing Address - City:ROCKY HILL
Mailing Address - State:CT
Mailing Address - Zip Code:06067
Mailing Address - Country:US
Mailing Address - Phone:860-257-7448
Mailing Address - Fax:860-257-9574
Practice Address - Street 1:368 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06114
Practice Address - Country:US
Practice Address - Phone:860-296-4411
Practice Address - Fax:860-296-9995
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT760111N00000X
CT451133N00000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004089571Medicaid
CT004089571Medicaid
350001069Medicare ID - Type Unspecified