Healthcare Provider Details

I. General information

NPI: 1962405282
Provider Name (Legal Business Name): MARTIN DESOMMA D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 02/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

276 HIGHLAND AVE
WATERBURY CT
06708-3022
US

IV. Provider business mailing address

276 HIGHLAND AVE
WATERBURY CT
06708-3022
US

V. Phone/Fax

Practice location:
  • Phone: 203-753-6384
  • Fax: 203-759-1705
Mailing address:
  • Phone: 203-753-6384
  • Fax: 203-759-1705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0100X
TaxonomyOccupational Health Chiropractor
License Number554
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: