Healthcare Provider Details

I. General information

NPI: 1265427983
Provider Name (Legal Business Name): STEVEN RICHARD SQUILLACE O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 04/22/2020
Certification Date: 04/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 SOUTH RD UNIT 8
SOMERS CT
06071-2160
US

IV. Provider business mailing address

P.O. BOX 801
SOMERS CT
06071-1206
US

V. Phone/Fax

Practice location:
  • Phone: 860-763-4733
  • Fax:
Mailing address:
  • Phone: 860-763-4733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number3270
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number2122
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: