Healthcare Provider Details

I. General information

NPI: 1518256122
Provider Name (Legal Business Name): JUSTIN DAVID RADOLF M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2011
Last Update Date: 04/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 FARMINGTON AVE E2018
FARMINGTON CT
06030-0001
US

IV. Provider business mailing address

23 SARAH DR
AVON CT
06001-3527
US

V. Phone/Fax

Practice location:
  • Phone: 860-679-8480
  • Fax: 860-679-1358
Mailing address:
  • Phone: 860-679-8480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number038013
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: