Healthcare Provider Details

I. General information

NPI: 1003504705
Provider Name (Legal Business Name): EYE CARE NORTHEAST SURGICAL PARTNERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2023
Last Update Date: 08/08/2023
Certification Date: 08/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 KENNEDY DR
PUTNAM CT
06260-1939
US

IV. Provider business mailing address

5 KENNEDY DR
PUTNAM CT
06260-1939
US

V. Phone/Fax

Practice location:
  • Phone: 860-928-0414
  • Fax:
Mailing address:
  • Phone: 860-928-0414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QS0132X
TaxonomyOphthalmologic Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JAMES DEAN
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 860-928-0414