Healthcare Provider Details

I. General information

NPI: 1447321146
Provider Name (Legal Business Name): RAPHAEL JOHN CAPASSO O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 07/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HAWLEY LN
TRUMBULL CT
06611-5330
US

IV. Provider business mailing address

100 HAWLEY LN
TRUMBULL CT
06611-5330
US

V. Phone/Fax

Practice location:
  • Phone: 203-378-9462
  • Fax: 203-378-9462
Mailing address:
  • Phone: 203-378-9462
  • Fax: 203-378-9462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number000890
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number000890
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: