Healthcare Provider Details

I. General information

NPI: 1174595490
Provider Name (Legal Business Name): DIMITRI GHECAS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 06/18/2024
Certification Date: 06/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 OLD PARK LANE
NEW MILFORD CT
06776
US

IV. Provider business mailing address

11 OLD PARK LANE
NEW MILFORD CT
06776
US

V. Phone/Fax

Practice location:
  • Phone: 860-355-1149
  • Fax: 860-355-5957
Mailing address:
  • Phone: 860-355-1149
  • Fax: 860-355-5957

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number022592
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number00735
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: