Healthcare Provider Details

I. General information

NPI: 1326362450
Provider Name (Legal Business Name): DR GOTAY ENT GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2010
Last Update Date: 12/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

171 GRANDVIEW AVENUE SUITE 203
WATERBURY CT
06708-2520
US

IV. Provider business mailing address

171 GRANDVIEW AVENUE SUITE 203
WATERBURY CT
06708-2520
US

V. Phone/Fax

Practice location:
  • Phone: 203-597-1002
  • Fax: 203-575-9846
Mailing address:
  • Phone: 203-597-1002
  • Fax: 203-575-9846

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number State

VIII. Authorized Official

Name: DR. VICTOR M GOTAY
Title or Position: OWNER
Credential: M.D.
Phone: 203-597-1002