Healthcare Provider Details

I. General information

NPI: 1497732564
Provider Name (Legal Business Name): EDWARD M EWALD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13 CHURCH RD
EAST GRANBY CT
06026-0518
US

IV. Provider business mailing address

PO BOX 518 13 CHURCH RD
EAST GRANBY CT
06026-0518
US

V. Phone/Fax

Practice location:
  • Phone: 860-653-4526
  • Fax: 860-653-5209
Mailing address:
  • Phone: 860-653-4526
  • Fax: 860-653-5209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number018024
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: