Healthcare Provider Details

I. General information

NPI: 1649353350
Provider Name (Legal Business Name): SUSAN F DELLERT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 04/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 SOUTH RD STE 120
FARMINGTON CT
06032-2483
US

IV. Provider business mailing address

10 COLUMBUS BLVD FL 4
HARTFORD CT
06106-1976
US

V. Phone/Fax

Practice location:
  • Phone: 860-837-6350
  • Fax:
Mailing address:
  • Phone: 860-837-5602
  • Fax: 860-837-5613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0008X
TaxonomyPediatric Neurodevelopmental Disabilities Physician
License NumberMA06455000
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code2080P0008X
TaxonomyPediatric Neurodevelopmental Disabilities Physician
License Number31703
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: