Healthcare Provider Details

I. General information

NPI: 1700239530
Provider Name (Legal Business Name): GREG E BUDOFF MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2016
Last Update Date: 09/01/2022
Certification Date: 09/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

191 MAIN ST STE 3
MANCHESTER CT
06042-3574
US

IV. Provider business mailing address

191 MAIN ST STE 3
MANCHESTER CT
06042-3574
US

V. Phone/Fax

Practice location:
  • Phone: 860-646-7704
  • Fax: 860-647-7340
Mailing address:
  • Phone: 860-646-7704
  • Fax: 860-647-7340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number70565
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License NumberA168607
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: