Healthcare Provider Details

I. General information

NPI: 1053628883
Provider Name (Legal Business Name): PLASTIC SURGERY OF SO CT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2010
Last Update Date: 08/31/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 POST RD W
WESTPORT CT
06880-4604
US

IV. Provider business mailing address

208 POST RD W
WESTPORT CT
06880-4604
US

V. Phone/Fax

Practice location:
  • Phone: 203-454-0044
  • Fax: 203-454-8675
Mailing address:
  • Phone: 203-454-0044
  • Fax: 203-454-8675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number024727
License Number StateCT

VIII. Authorized Official

Name: DR. JOSEPH B O'CONNELL
Title or Position: M.D.
Credential: M.D.
Phone: 203-454-0044