Healthcare Provider Details

I. General information

NPI: 1588636807
Provider Name (Legal Business Name): PETER J. BRANDEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 06/26/2024
Certification Date: 06/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 W MAIN ST SUITE 100
WATERBURY CT
06708-3105
US

IV. Provider business mailing address

1201 W MAIN ST SUITE 100
WATERBURY CT
06708-3105
US

V. Phone/Fax

Practice location:
  • Phone: 203-597-9100
  • Fax: 203-596-4758
Mailing address:
  • Phone: 203-597-9100
  • Fax: 203-401-6517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number031640
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License Number31640
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: