Provider Demographics
NPI:1407318363
Name:GOETTEMOELLER, TRAVIS (MD)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:GOETTEMOELLER
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 1:292 LONG RIDGE RD STE 206
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-1627
Mailing Address - Country:US
Mailing Address - Phone:203-276-7213
Mailing Address - Fax:203-276-4975
Practice Address - Street 1:292 LONG RIDGE RD STE 206
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-1627
Practice Address - Country:US
Practice Address - Phone:203-276-7213
Practice Address - Fax:203-276-4975
Is Sole Proprietor?:No
Enumeration Date:2019-04-01
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT078165207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism