Healthcare Provider Details

I. General information

NPI: 1275933095
Provider Name (Legal Business Name): CROSSROADS PRIMARY CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2014
Last Update Date: 04/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

196 PARKWAY S SUITE 304
WATERFORD CT
06385-1234
US

IV. Provider business mailing address

196 PARKWAY S SUITE 304
WATERFORD CT
06385-1234
US

V. Phone/Fax

Practice location:
  • Phone: 860-440-7525
  • Fax: 860-447-8961
Mailing address:
  • Phone: 860-442-7027
  • Fax: 860-444-0074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number StateCT

VIII. Authorized Official

Name: DR. MITHLESH GOVIL
Title or Position: OWNER / PHYSICIAN
Credential: M.D.
Phone: 860-443-4455