Healthcare Provider Details

I. General information

NPI: 1710099288
Provider Name (Legal Business Name): AMAL DAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 03/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

580 COTTAGE GROVE RD STE 206
BLOOMFIELD CT
06002-3088
US

IV. Provider business mailing address

580 COTTAGE GROVE RD STE 206
BLOOMFIELD CT
06002-3088
US

V. Phone/Fax

Practice location:
  • Phone: 860-242-0774
  • Fax: 860-242-7444
Mailing address:
  • Phone: 860-242-0774
  • Fax: 860-242-7444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number017289
License Number StateCT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1172899
Identifier TypeMEDICAID
Identifier StateCT
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: