Healthcare Provider Details

I. General information

NPI: 1427053032
Provider Name (Legal Business Name): JANE M BROTANEK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38B GROVE STREET RIDGEFIELD PEDIATRIC ASSOCIATES
RIDGEFIELD CT
06877
US

IV. Provider business mailing address

38B GROVE STREET RIDGEFIELD PEDIATRIC ASSOCIATES
RIDGEFIELD CT
06877
US

V. Phone/Fax

Practice location:
  • Phone: 203-438-9557
  • Fax: 203-438-7857
Mailing address:
  • Phone: 203-438-9557
  • Fax: 203-438-7857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number47361
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number050206
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: