Healthcare Provider Details

I. General information

NPI: 1306053160
Provider Name (Legal Business Name): VAIBHAV MEHENDIRATTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 WESTERN BLVD STE A
GLASTONBURY CT
06033-4305
US

IV. Provider business mailing address

30 WATERCHASE DR
ROCKY HILL CT
06067-2110
US

V. Phone/Fax

Practice location:
  • Phone: 860-657-1920
  • Fax: 860-657-1925
Mailing address:
  • Phone: 860-257-4131
  • Fax: 860-457-4519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number054639
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: