Healthcare Provider Details

I. General information

NPI: 1841292802
Provider Name (Legal Business Name): HAL LAWRENCE OSTROM O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2005
Last Update Date: 01/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 E MAIN ST UNIT 4
CLINTON CT
06413-2120
US

IV. Provider business mailing address

116 E MAIN ST UNIT 4
CLINTON CT
06413-2120
US

V. Phone/Fax

Practice location:
  • Phone: 860-669-2020
  • Fax:
Mailing address:
  • Phone: 860-669-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2017
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number2017
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: