Healthcare Provider Details

I. General information

NPI: 1497732101
Provider Name (Legal Business Name): EVAN P PROVISOR MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2005
Last Update Date: 08/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 HOSPITAL HILL RD SUITE 1600
SHARON CT
06069-2095
US

IV. Provider business mailing address

PO BOX 786
SHARON CT
06069-0786
US

V. Phone/Fax

Practice location:
  • Phone: 860-364-0226
  • Fax: 860-364-0875
Mailing address:
  • Phone: 860-364-0226
  • Fax: 860-364-0875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateCT

VIII. Authorized Official

Name: EVAN PAUL PROVISOR
Title or Position: PRESIDENT
Credential: MD
Phone: 860-364-0226