Healthcare Provider Details

I. General information

NPI: 1598887218
Provider Name (Legal Business Name): MARC N POTENZA MD PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 VANCE DRIVE CONNECTICUT VALLEY HOSPITAL PROBLEM GAMBLING SERVICES R
MIDDLETOWN CT
06457
US

IV. Provider business mailing address

PO BOX 351 2 VANCE DRIVE CONNECTICUT VALLEY HOSPITAL PROBLEM GAMBL
MIDDLETOWN CT
06457
US

V. Phone/Fax

Practice location:
  • Phone: 860-344-2244
  • Fax: 860-344-2360
Mailing address:
  • Phone: 860-344-2244
  • Fax: 860-344-2360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number035340
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: