=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093890162
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TONYA CREMIN D.O.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2006
-----------------------------------------------------
Last Update Date | 11/03/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 324 ELM ST STE 203A
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06468-2282
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-445-9060
-----------------------------------------------------
Fax | 203-445-9093
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 324 ELM ST STE 203A
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06468-2282
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-445-9060
-----------------------------------------------------
Fax | 203-445-9093
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 044753
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------