Healthcare Provider Details

I. General information

NPI: 1497925044
Provider Name (Legal Business Name): LATESHA I DAWSON THOMAS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2008
Last Update Date: 11/18/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 ASH ST UCONN MEDICAL GROUP-PEDIATRICS
EAST HARTFORD CT
06108-3226
US

IV. Provider business mailing address

264 FARMINGTON AVENUE PROVIDER ENROLLMENT
FARMINGTON CT
06030-2212
US

V. Phone/Fax

Practice location:
  • Phone: 860-282-3859
  • Fax: 860-282-8574
Mailing address:
  • Phone: 860-679-7503
  • Fax: 860-679-1610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number046993
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: