Healthcare Provider Details

I. General information

NPI: 1114928827
Provider Name (Legal Business Name): SPECIALISTS IN WOMEN'S HEALTHCARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2005
Last Update Date: 04/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 GRANDVIEW AVE STE 210
WATERBURY CT
06708-2507
US

IV. Provider business mailing address

134 GRANDVIEW AVE STE 210
WATERBURY CT
06708-2507
US

V. Phone/Fax

Practice location:
  • Phone: 203-754-2535
  • Fax: 203-754-0788
Mailing address:
  • Phone: 203-754-2535
  • Fax: 203-754-0788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN CONRAD KACZMAREK
Title or Position: MD PRESIDENT
Credential: MD
Phone: 203-754-2535