Healthcare Provider Details

I. General information

NPI: 1861306102
Provider Name (Legal Business Name): FERNANDO MATEO LOZADA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2026
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12A LEDGEBROOK DR
MANSFIELD CENTER CT
06250-1690
US

IV. Provider business mailing address

411 VALLEY ST
WILLIMANTIC CT
06226-2073
US

V. Phone/Fax

Practice location:
  • Phone: 860-423-2960
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number1144391244
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: