Provider Demographics
NPI:1285623538
Name:CAPORASO, EDMUND F (MD)
Entity type:Individual
Prefix:
First Name:EDMUND
Middle Name:F
Last Name:CAPORASO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1567 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06705-1026
Mailing Address - Country:US
Mailing Address - Phone:203-597-9778
Mailing Address - Fax:203-757-0367
Practice Address - Street 1:1567 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06705-1026
Practice Address - Country:US
Practice Address - Phone:203-597-9778
Practice Address - Fax:203-757-0367
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-19
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0262476207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1262476Medicaid
CT1262476Medicaid
B38979Medicare UPIN