Healthcare Provider Details

I. General information

NPI: 1982793741
Provider Name (Legal Business Name): LEO JOHN WOLANSKY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: LEO IVAN (JOHN) WOLANSKY M.D.

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 11/07/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UCONN MEDICAL GROUP 263 FARMINGTON AVENUE
FARMINGTON CT
06030-1714
US

IV. Provider business mailing address

UCONN MEDICAL GROUP 263 FARMINGTON AVENUE
FARMINGTON CT
06030-1714
US

V. Phone/Fax

Practice location:
  • Phone: 860-679-2784
  • Fax: 860-679-3145
Mailing address:
  • Phone: 860-679-2784
  • Fax: 860-679-3145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number35.099275
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number35.099275
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number35.099275
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number029944
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: