Provider Demographics
NPI:1851468243
Name:POLEZONIS, STEPHEN N (OD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:N
Last Name:POLEZONIS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 BOTELLE MNR
Mailing Address - Street 2:
Mailing Address - City:CROMWELL
Mailing Address - State:CT
Mailing Address - Zip Code:06416-1301
Mailing Address - Country:US
Mailing Address - Phone:860-635-5758
Mailing Address - Fax:
Practice Address - Street 1:198 E MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06051-1915
Practice Address - Country:US
Practice Address - Phone:860-223-7900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002150152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T23315Medicare UPIN
410000428Medicare ID - Type Unspecified