Healthcare Provider Details

I. General information

NPI: 1699747832
Provider Name (Legal Business Name): PAUL MARUSOV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76 SPRING ROCK RD
EAST LYME CT
06333-1440
US

IV. Provider business mailing address

76 SPRING ROCK RD
EAST LYME CT
06333-1440
US

V. Phone/Fax

Practice location:
  • Phone: 860-739-2407
  • Fax:
Mailing address:
  • Phone: 860-739-2407
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number025201
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: