Healthcare Provider Details

I. General information

NPI: 1194305524
Provider Name (Legal Business Name): KODILICHI VJ BALDINO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2021
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 HARTFORD RD
MANCHESTER CT
06040-5921
US

IV. Provider business mailing address

71 HAYNES ST
MANCHESTER CT
06040-4131
US

V. Phone/Fax

Practice location:
  • Phone: 860-533-4673
  • Fax:
Mailing address:
  • Phone: 860-533-4679
  • Fax: 860-645-4151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD30452
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number82055
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: