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General NPI Number Information
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NPI Number | 1164835153
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Entity Type | Organization
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Legal Business Name | FARMINGTON VALLEY DERMATOLOGY AND SURGERY, LLC
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Dates
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Enumeration Date | 06/06/2014
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Last Update Date | 03/14/2024
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Provider Practice Location Address
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Address Line | 30 W AVON RD STE E
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City | AVON
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State | CT
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Zip | 06001-3678
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Country | US
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Telephone | 860-674-9900
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Fax | 860-678-0036
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Provider Business Mailing Address
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Address Line | 30 W AVON RD STE E
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City | AVON
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State | CT
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Zip | 06001-3678
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Country | US
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Telephone | 561-654-1789
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Fax | 508-304-7532
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Authorized Official
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Title or Position | OWNER
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Name | DR. SADAF WAQAR
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Credential | DO
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Telephone | 860-674-9900
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332900000X
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Taxonomy Name | Non-Pharmacy Dispensing Site
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 53002
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License Number State | CT
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