Healthcare Provider Details

I. General information

NPI: 1003898172
Provider Name (Legal Business Name): RICHARD M. KETAI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 S MAIN ST
MIDDLETOWN CT
06457-3651
US

IV. Provider business mailing address

103 S MAIN ST
MIDDLETOWN CT
06457-3651
US

V. Phone/Fax

Practice location:
  • Phone: 860-358-8760
  • Fax: 860-358-8754
Mailing address:
  • Phone: 860-358-8760
  • Fax: 860-358-8754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number029296
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: