Healthcare Provider Details

I. General information

NPI: 1538452594
Provider Name (Legal Business Name): LOIS WURZEL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2011
Last Update Date: 05/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 BAYBERRY HILL RD
AVON CT
06001-2800
US

IV. Provider business mailing address

77 BAYBERRY HILL RD
AVON CT
06001-2800
US

V. Phone/Fax

Practice location:
  • Phone: 860-558-6527
  • Fax: 860-678-8895
Mailing address:
  • Phone: 860-676-1981
  • Fax: 860-678-8895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number025894
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: