Healthcare Provider Details

I. General information

NPI: 1326138108
Provider Name (Legal Business Name): LORI C STETZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 01/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1291 BOSTON POST RD SUITE 105
MADISON CT
06443-3476
US

IV. Provider business mailing address

28 CRESCENT ST
MIDDLETOWN CT
06457-3654
US

V. Phone/Fax

Practice location:
  • Phone: 203-245-1413
  • Fax: 203-318-0814
Mailing address:
  • Phone: 860-358-4819
  • Fax: 860-358-4809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number043780
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: