Provider Demographics
NPI:1487752903
Name:IPPOLITO, RAYMOND JOSEPH (MD)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:JOSEPH
Last Name:IPPOLITO
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 1:420 EAST MAIN STREET
Mailing Address - Street 2:BLDG 2 UNIT 5
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405
Mailing Address - Country:US
Mailing Address - Phone:203-481-6722
Mailing Address - Fax:203-483-2074
Practice Address - Street 1:420 EAST MAIN STREET
Practice Address - Street 2:BLDG 2 UNIT 5
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405
Practice Address - Country:US
Practice Address - Phone:203-481-6722
Practice Address - Fax:203-483-2074
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT016865208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
709727OtherCONNECTICARE
010016865CT01OtherBCBS
0Q1189OtherHEALTHNET
709727OtherCONNECTICARE
B83539Medicare UPIN