Healthcare Provider Details

I. General information

NPI: 1942735659
Provider Name (Legal Business Name): SAMUEL WERNER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2017
Last Update Date: 11/22/2022
Certification Date: 11/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

342 N MAIN ST STE 350
WEST HARTFORD CT
06117-2500
US

IV. Provider business mailing address

342 N MAIN ST STE 350
WEST HARTFORD CT
06117-2500
US

V. Phone/Fax

Practice location:
  • Phone: 860-331-3016
  • Fax: 860-331-3019
Mailing address:
  • Phone: 860-331-3016
  • Fax: 860-331-3019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number71101
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number25MB11231200
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MB11231200
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOT017661
License Number StatePA
# 5
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number71101
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: