Healthcare Provider Details

I. General information

NPI: 1386136745
Provider Name (Legal Business Name): DAVID ANTHONY BARTOLOTTA JR. ATC, EMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2018
Last Update Date: 06/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 HIDDEN LAKE RD
HIGGANUM CT
06441-4527
US

IV. Provider business mailing address

160 HIDDEN LAKE RD
HIGGANUM CT
06441-4527
US

V. Phone/Fax

Practice location:
  • Phone: 860-754-7341
  • Fax:
Mailing address:
  • Phone: 860-754-7341
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number000864
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: