Healthcare Provider Details

I. General information

NPI: 1902434624
Provider Name (Legal Business Name): PADMINI CHANNAMSETTY DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2020
Last Update Date: 08/06/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 S MAIN ST STE 103
CHESHIRE CT
06410-3112
US

IV. Provider business mailing address

1290 SILAS DEANE HWY
WETHERSFIELD CT
06109-4337
US

V. Phone/Fax

Practice location:
  • Phone: 860-696-2925
  • Fax: 860-696-2926
Mailing address:
  • Phone: 860-972-9034
  • Fax: 860-972-7040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number77992
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number77992
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: