Healthcare Provider Details

I. General information

NPI: 1558338079
Provider Name (Legal Business Name): LOUISE GIAMMONA CAUDULLO D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2006
Last Update Date: 07/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 UNION ST
VERNON CT
06066-3126
US

IV. Provider business mailing address

11 SHODDY MILL RD
BOLTON CT
06043-7817
US

V. Phone/Fax

Practice location:
  • Phone: 860-872-5291
  • Fax:
Mailing address:
  • Phone: 860-645-0115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number531
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: