Healthcare Provider Details

I. General information

NPI: 1225014731
Provider Name (Legal Business Name): ETHAN B. FOXMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 01/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 SEYMOUR ST SUITE 200
HARTFORD CT
06106-5501
US

IV. Provider business mailing address

111 FOUNDERS PLZ SUITE 400
EAST HARTFORD CT
06108-3212
US

V. Phone/Fax

Practice location:
  • Phone: 860-289-3375
  • Fax: 860-560-2849
Mailing address:
  • Phone: 860-291-6554
  • Fax: 860-783-5733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number213770
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number042224
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number213770
License Number StateMA
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number42224
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: