Healthcare Provider Details

I. General information

NPI: 1164835153
Provider Name (Legal Business Name): FARMINGTON VALLEY DERMATOLOGY AND SURGERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2014
Last Update Date: 03/14/2024
Certification Date: 03/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 W AVON RD STE E
AVON CT
06001-3678
US

IV. Provider business mailing address

30 W AVON RD STE E
AVON CT
06001-3678
US

V. Phone/Fax

Practice location:
  • Phone: 860-674-9900
  • Fax: 860-678-0036
Mailing address:
  • Phone: 561-654-1789
  • Fax: 508-304-7532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number53002
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: DR. SADAF WAQAR
Title or Position: OWNER
Credential: DO
Phone: 860-674-9900