Healthcare Provider Details

I. General information

NPI: 1164516068
Provider Name (Legal Business Name): GREATER WATERBURY RETINA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 06/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 WATERBURY RD SUITE 201
PROSPECT CT
06712-1200
US

IV. Provider business mailing address

166 WATERBURY RD SUITE 201
PROSPECT CT
06712-1200
US

V. Phone/Fax

Practice location:
  • Phone: 203-758-5733
  • Fax: 203-758-7400
Mailing address:
  • Phone: 203-758-5733
  • Fax: 203-758-7400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: NEAL JASON ZIMMERMAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 203-758-5733