Healthcare Provider Details

I. General information

NPI: 1740271816
Provider Name (Legal Business Name): RICK CROLLA O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2005
Last Update Date: 09/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 EAST AVE
NEW CANAAN CT
06840-5516
US

IV. Provider business mailing address

317 MAIN ST
NEW CANAAN CT
06840-5837
US

V. Phone/Fax

Practice location:
  • Phone: 203-966-9480
  • Fax:
Mailing address:
  • Phone: 203-972-3287
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1027
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: