Healthcare Provider Details

I. General information

NPI: 1518090265
Provider Name (Legal Business Name): GLENN H SEGAL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 WATSON BLVD
STRATFORD CT
06615-7127
US

IV. Provider business mailing address

46 SULLIVAN RD
NEW MILFORD CT
06776-4552
US

V. Phone/Fax

Practice location:
  • Phone: 203-380-4585
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License Number000453
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: