Healthcare Provider Details

I. General information

NPI: 1114150588
Provider Name (Legal Business Name): JAIRO MAURICIO MONTEZUMA- RUSCA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2009
Last Update Date: 07/11/2022
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: 860-679-3245
  • Fax: 860-679-0121
Mailing address:
  • Phone: 860-679-3692
  • Fax: 860-679-7077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number52396
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: