Healthcare Provider Details

I. General information

NPI: 1649403320
Provider Name (Legal Business Name): INTEGRATED MEDICAL OF DANBURY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2009
Last Update Date: 09/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46 MILL PLAIN RD
DANBURY CT
06811-5140
US

IV. Provider business mailing address

46 MILL PLAIN RD
DANBURY CT
06811-5140
US

V. Phone/Fax

Practice location:
  • Phone: 203-297-6120
  • Fax: 203-297-6122
Mailing address:
  • Phone: 203-297-6120
  • Fax: 203-297-6122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number031959
License Number StateCT

VIII. Authorized Official

Name: DR. MICHAEL LANCE GERSTENFELD
Title or Position: OWNER/MANAGER
Credential: M.D.
Phone: 203-297-6120