Healthcare Provider Details

I. General information

NPI: 1417965575
Provider Name (Legal Business Name): KENNETH ROBERT COLLITON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 04/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 GRAND ST
NEW BRITIAN CT
06050
US

IV. Provider business mailing address

68 S SERVICE RD SUITE 350
MELVILLE NC
22033-2921
US

V. Phone/Fax

Practice location:
  • Phone: 860-224-5266
  • Fax:
Mailing address:
  • Phone: 516-945-3000
  • Fax: 516-945-3131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number034359
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: