Healthcare Provider Details

I. General information

NPI: 1922084540
Provider Name (Legal Business Name): MASONICARE PRIMARY CARE PHYSICIANS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2005
Last Update Date: 01/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67 MASONIC AVENUE 1ST FLOOR
WALLINGFORD CT
06492
US

IV. Provider business mailing address

67 MASONIC AVENUE 1ST FLOOR
WALLINGFORD CT
06492
US

V. Phone/Fax

Practice location:
  • Phone: 203-265-0355
  • Fax: 203-265-7413
Mailing address:
  • Phone: 203-265-0355
  • Fax: 203-265-7413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: ALLA BERNSHTEYN
Title or Position: PRESIDENT
Credential: MD
Phone: 203-265-0355