Healthcare Provider Details

I. General information

NPI: 1760660641
Provider Name (Legal Business Name): FOOT AND ANKLE SPECIALISTS OF THE MID-ATLANTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2008
Last Update Date: 09/07/2023
Certification Date: 09/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

714 CHASE PKWY SUITE 4
WATERBURY CT
06708-3012
US

IV. Provider business mailing address

714 CHASE PKWY SUITE 4
WATERBURY CT
06708-3012
US

V. Phone/Fax

Practice location:
  • Phone: 203-755-0489
  • Fax: 203-755-7523
Mailing address:
  • Phone: 203-755-0489
  • Fax: 203-755-7523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number548
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number548
License Number StateCT

VIII. Authorized Official

Name: MICHAEL TRITTO
Title or Position: DPM/OWNER
Credential:
Phone: 301-933-7133