Provider Demographics
NPI:1992563902
Name:FARMINGTON VALLEY DERMATOLOGY AND SURGERY, LLC
Entity type:Organization
Organization Name:FARMINGTON VALLEY DERMATOLOGY AND SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:SADAF
Authorized Official - Middle Name:
Authorized Official - Last Name:WAQAR
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:860-674-9900
Mailing Address - Street 1:30 W AVON RD
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-3678
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2400 TAMARACK AVE STE 203
Practice Address - Street 2:
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-5559
Practice Address - Country:US
Practice Address - Phone:860-674-9900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FARMINGTON VALLEY DERMATOLOGY & SURGERY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-03-13
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site