Healthcare Provider Details

I. General information

NPI: 1760640650
Provider Name (Legal Business Name): JONATHAN S.L EARLE M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2008
Last Update Date: 05/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 FOUNDERS PLZ STE 300
EAST HARTFORD CT
06108-8307
US

IV. Provider business mailing address

111 FOUNDERS PLZ STE 300
EAST HARTFORD CT
06108-8307
US

V. Phone/Fax

Practice location:
  • Phone: 860-282-4022
  • Fax:
Mailing address:
  • Phone: 860-282-4022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number046577
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: