Healthcare Provider Details

I. General information

NPI: 1003864497
Provider Name (Legal Business Name): MARK JUSTIN FLETCHER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 01/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

761 MAIN AVE SUITE 115
NORWALK CT
06851-1080
US

IV. Provider business mailing address

761 MAIN AVE SUITE 115
NORWALK CT
06851-1080
US

V. Phone/Fax

Practice location:
  • Phone: 203-845-2200
  • Fax: 203-847-1940
Mailing address:
  • Phone: 203-845-2200
  • Fax: 203-847-1940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD26914
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: