Healthcare Provider Details

I. General information

NPI: 1427383579
Provider Name (Legal Business Name): CONNECTICUT ADVANCED EYECARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2009
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67 WELLS RD
WETHERSFIELD CT
06109-3043
US

IV. Provider business mailing address

67 WELLS RD
WETHERSFIELD CT
06109-3043
US

V. Phone/Fax

Practice location:
  • Phone: 860-529-5429
  • Fax: 860-563-5202
Mailing address:
  • Phone: 860-529-5429
  • Fax: 860-563-5202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number2672
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number2672
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2672
License Number StateCT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MAHA LAKSHMI RAMAMURTHY
Title or Position: OPTOMETRIST
Credential: OD, MS
Phone: 860-529-5429