Provider Demographics
NPI:1528161551
Name:DERMATOLOGY ASSOCIATES OF WTBY PC
Entity type:Organization
Organization Name:DERMATOLOGY ASSOCIATES OF WTBY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SALVATORE
Authorized Official - Middle Name:V
Authorized Official - Last Name:ROMANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-757-8919
Mailing Address - Street 1:171 GRANDVIEW AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2517
Mailing Address - Country:US
Mailing Address - Phone:203-757-8919
Mailing Address - Fax:203-756-4697
Practice Address - Street 1:171 GRANDVIEW AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2517
Practice Address - Country:US
Practice Address - Phone:203-757-8919
Practice Address - Fax:203-756-4697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
07D0100073OtherBLUE CROSS NUMBER CLIA
CT004001756Medicaid
CT070000151OtherMEDICARE GROUP #
07D0100073OtherBLUE CROSS NUMBER CLIA