Healthcare Provider Details

I. General information

NPI: 1457778193
Provider Name (Legal Business Name): ADVANCED OPHTHALMOLOGY OF CONNECTICUT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2014
Last Update Date: 01/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1455 EAST PUTNAM AVENUE
OLD GREENWICH CT
06870
US

IV. Provider business mailing address

1455 EAST PUTNUM AVENUE
OLD GREENWICH CT
06870
US

V. Phone/Fax

Practice location:
  • Phone: 203-348-7573
  • Fax: 203-348-2893
Mailing address:
  • Phone: 203-348-7573
  • Fax: 203-348-2893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number35457
License Number StateCT

VIII. Authorized Official

Name: ROBERT JOSEPH FUCIGNA
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 203-348-7575