Healthcare Provider Details

I. General information

NPI: 1366439036
Provider Name (Legal Business Name): ROBERT W. ELWELL JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2005
Last Update Date: 01/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 MASONIC AVE. 1ST FLR
WALLINGFORD CT
06492
US

IV. Provider business mailing address

22 MASONIC AVE. 1ST FLOOR
WALLINGFORD CT
06492
US

V. Phone/Fax

Practice location:
  • Phone: 203-679-5900
  • Fax: 203-679-6873
Mailing address:
  • Phone: 203-679-5900
  • Fax: 203-679-6873

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number21753
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: