Healthcare Provider Details

I. General information

NPI: 1457332181
Provider Name (Legal Business Name): MATTHEW PATRICK RAYMOND D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 06/30/2021
Certification Date: 06/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 N MAIN ST
SOUTHINGTON CT
06489-2529
US

IV. Provider business mailing address

340 NORTH MAIN ST.
SOUTHINGTON CT
06489
US

V. Phone/Fax

Practice location:
  • Phone: 860-628-3111
  • Fax: 860-628-3119
Mailing address:
  • Phone: 860-628-3111
  • Fax: 860-628-3119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number000534
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: