Healthcare Provider Details

I. General information

NPI: 1124019377
Provider Name (Legal Business Name): MARK S SAFALOW MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2005
Last Update Date: 07/13/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 FARMINGTON AVE
FARMINGTON CT
06030-0001
US

IV. Provider business mailing address

263 FARMINGTON AVE
FARMINGTON CT
06030-8082
US

V. Phone/Fax

Practice location:
  • Phone: 860-679-4477
  • Fax: 860-679-8770
Mailing address:
  • Phone: 860-679-4477
  • Fax: 860-679-8770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number040630
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number40630
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: