=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023471273
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRENDAN GONTARZ MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2016
-----------------------------------------------------
Last Update Date | 06/22/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 263 FARMINGTON AVE
-----------------------------------------------------
City | FARMINGTON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06030-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-679-3467
-----------------------------------------------------
Fax | 860-679-1460
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1290 SILAS DEANE HWY
-----------------------------------------------------
City | WETHERSFIELD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06109-4337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-972-9093
-----------------------------------------------------
Fax | 860-972-7040
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 75034
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------