Healthcare Provider Details

I. General information

NPI: 1649291980
Provider Name (Legal Business Name): RANDALL R DWENGER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 06/04/2021
Certification Date: 06/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

187 S CANAAN RD
CANAAN CT
06018-2544
US

IV. Provider business mailing address

30 CEDAR CREST PO BOX 443
SALISBURY CT
06068-0443
US

V. Phone/Fax

Practice location:
  • Phone: 860-824-1397
  • Fax: 888-690-2727
Mailing address:
  • Phone: 917-513-7438
  • Fax: 888-690-2727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number183297
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: