Healthcare Provider Details

I. General information

NPI: 1306821863
Provider Name (Legal Business Name): JEFFREY ROBERT BREITER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2005
Last Update Date: 03/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 TAMARACK AVE SUITE 101
SOUTH WINDSOR CT
06074-5539
US

IV. Provider business mailing address

2139 SILAS DEANE HWY
ROCKY HILL CT
06067-2336
US

V. Phone/Fax

Practice location:
  • Phone: 860-644-4442
  • Fax: 860-644-1412
Mailing address:
  • Phone: 860-257-4131
  • Fax: 860-257-4519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number021746
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: