Healthcare Provider Details

I. General information

NPI: 1689841520
Provider Name (Legal Business Name): ANSONIA PODIATRY ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2008
Last Update Date: 01/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

364 E MAIN ST
ANSONIA CT
06401-1904
US

IV. Provider business mailing address

364 E MAIN ST
ANSONIA CT
06401-1904
US

V. Phone/Fax

Practice location:
  • Phone: 203-734-4806
  • Fax: 203-734-8265
Mailing address:
  • Phone: 203-734-4806
  • Fax: 203-734-8265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number000678
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number000678
License Number StateCT

VIII. Authorized Official

Name: DR. MICHAEL S TRAVISANO
Title or Position: OWNER
Credential: D.P.M.
Phone: 203-734-4806