Healthcare Provider Details

I. General information

NPI: 1407353105
Provider Name (Legal Business Name): JUSTIN RACKLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2018
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 IVY BROOK RD STE 120
SHELTON CT
06484-6417
US

IV. Provider business mailing address

67 MAPLE AVE
DERBY CT
06418-1328
US

V. Phone/Fax

Practice location:
  • Phone: 203-732-1524
  • Fax: 203-954-0084
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number83848
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number83848
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: