Healthcare Provider Details

I. General information

NPI: 1194760579
Provider Name (Legal Business Name): GREGORY J KUNDRAT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 04/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 GROVE BEACH RD NORTH BUILDING 1, UNIT A
WESTBROOK CT
06498
US

IV. Provider business mailing address

28 CRESCENT ST
MIDDLETOWN CT
06457-3654
US

V. Phone/Fax

Practice location:
  • Phone: 860-664-3553
  • Fax: 860-664-3756
Mailing address:
  • Phone: 860-358-4819
  • Fax: 860-358-4809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number018585
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: