Healthcare Provider Details

I. General information

NPI: 1144484213
Provider Name (Legal Business Name): CONNECTICUT FOOT SPECIALISTS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2008
Last Update Date: 09/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 ASYLUM AVENUE SUITE 2100
HARTFORD CT
06105
US

IV. Provider business mailing address

133 HARTFORD AVENUE
EAST GRANBY CT
06026
US

V. Phone/Fax

Practice location:
  • Phone: 860-714-3668
  • Fax: 860-714-8123
Mailing address:
  • Phone: 860-653-4708
  • Fax: 860-653-6249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number StateCT

VIII. Authorized Official

Name: DR. BRIAN K WAGNER
Title or Position: OWNER
Credential: DPM
Phone: 860-653-4708