Provider Demographics
NPI:1699964403
Name:CARDIOMED OF CONNECTICUT, LLC
Entity type:Organization
Organization Name:CARDIOMED OF CONNECTICUT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHUMMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:RAZA
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FACC
Authorized Official - Phone:203-371-5189
Mailing Address - Street 1:4695 MAIN ST
Mailing Address - Street 2:SUITE 19
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-1802
Mailing Address - Country:US
Mailing Address - Phone:203-371-5189
Mailing Address - Fax:203-372-6365
Practice Address - Street 1:4695 MAIN ST
Practice Address - Street 2:SUITE 19
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-1802
Practice Address - Country:US
Practice Address - Phone:203-371-5189
Practice Address - Fax:203-372-6365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-17
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT036793207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001367938Medicaid
CTC02366Medicare UPIN