Healthcare Provider Details

I. General information

NPI: 1356403323
Provider Name (Legal Business Name): NEW MILFORD MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 09/15/2025
Certification Date: 09/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 OLD PARK LANE RD
NEW MILFORD CT
06776-2507
US

IV. Provider business mailing address

11 OLD PARK LANE RD
NEW MILFORD CT
06776-2507
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 TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MARIA MARTINEZ
Title or Position: CREDENTIALING COORDINATOR
Credential: CPC, CPCS
Phone: 860-350-7685