Healthcare Provider Details

I. General information

NPI: 1780732289
Provider Name (Legal Business Name): WILLIMAUTIC PEDIATRICS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 MANSFIELD AVENUE
WILLIMAUTIC CT
06226-2020
US

IV. Provider business mailing address

70 MANSFIELD AVENUE
WILLIMAUTIC CT
06226-2020
US

V. Phone/Fax

Practice location:
  • Phone: 860-456-1132
  • Fax: 860-456-2023
Mailing address:
  • Phone: 860-456-1132
  • Fax: 860-456-2023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateCT

VIII. Authorized Official

Name: MRS. DAMARIS R ORTIZ
Title or Position: OFFICE MANAGER
Credential:
Phone: 860-456-1132