Healthcare Provider Details

I. General information

NPI: 1477059772
Provider Name (Legal Business Name): JUSTIN D'ADDARIO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2018
Last Update Date: 08/24/2023
Certification Date: 08/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1402 S GRAND BLVD # M260
SAINT LOUIS MO
63104-1004
US

IV. Provider business mailing address

263 FARMINGTON AVE
FARMINGTON CT
06030-8082
US

V. Phone/Fax

Practice location:
  • Phone: 845-656-7412
  • Fax:
Mailing address:
  • Phone: 606-798-0808
  • Fax: 860-679-1430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number075022
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: