Healthcare Provider Details

I. General information

NPI: 1316524804
Provider Name (Legal Business Name): SUSAN FLAHERTY WASHBURN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUSAN FLAHERTY KOSTIN MD

II. Dates (important events)

Enumeration Date: 03/29/2021
Last Update Date: 07/22/2024
Certification Date: 07/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

357 HARTFORD TPKE
VERNON CT
06066-4838
US

IV. Provider business mailing address

357 HARTFORD TPKE
VERNON CT
06066-4838
US

V. Phone/Fax

Practice location:
  • Phone: 860-871-2102
  • Fax: 860-870-0890
Mailing address:
  • Phone: 860-871-2102
  • Fax: 860-870-0890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number78563
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: