Healthcare Provider Details

I. General information

NPI: 1457419616
Provider Name (Legal Business Name): BENOIT D TANO MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 10/14/2024
Certification Date: 10/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 HEBRON AVE
GLASTONBURY CT
06033-2421
US

IV. Provider business mailing address

622 HEBRON AVE
GLASTONBURY CT
06033-2421
US

V. Phone/Fax

Practice location:
  • Phone: 860-659-8904
  • Fax:
Mailing address:
  • Phone: 860-659-8904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License NumberPT11501
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberM4963
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: