Healthcare Provider Details

I. General information

NPI: 1336781236
Provider Name (Legal Business Name): WATERFORD VASCULAR ASSOCIATES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2019
Last Update Date: 10/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

903 HARTFORD TPKE UNIT 30
WATERFORD CT
06385-4264
US

IV. Provider business mailing address

2001 BUTTERFIELD RD STE 300
DOWNERS GROVE IL
60515-1069
US

V. Phone/Fax

Practice location:
  • Phone: 860-772-1998
  • Fax: 860-772-1999
Mailing address:
  • Phone: 630-725-2700
  • Fax: 833-842-5469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: LORENA ESPARZA
Title or Position: REVENUE CYCLE MANAGER
Credential:
Phone: 630-725-2764