Provider Demographics
NPI:1972713253
Name:JON GAUDIO LLC
Entity type:Organization
Organization Name:JON GAUDIO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:C
Authorized Official - Last Name:GAUDIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-536-6278
Mailing Address - Street 1:393 FISHTOWN RD
Mailing Address - Street 2:
Mailing Address - City:MYSTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06355-2039
Mailing Address - Country:US
Mailing Address - Phone:860-536-6278
Mailing Address - Fax:
Practice Address - Street 1:393 FISHTOWN RD
Practice Address - Street 2:
Practice Address - City:MYSTIC
Practice Address - State:CT
Practice Address - Zip Code:06355-2039
Practice Address - Country:US
Practice Address - Phone:860-536-6278
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT040569207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC03182Medicare ID - Type Unspecified