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General NPI Number Information
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NPI Number | 1457793291
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Entity Type | Organization
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Legal Business Name | MGDA
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Dates
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Enumeration Date | 07/22/2013
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Last Update Date | 07/22/2013
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Provider Practice Location Address
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Address Line | 146 HIGHLAND AVE
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City | WATERBURY
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State | CT
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Zip | 06708-2761
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Country | US
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Telephone | 203-755-7748
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Fax | 203-755-7784
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Provider Business Mailing Address
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Address Line | 146 HIGHLAND AVE
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City | WATERBURY
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State | CT
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Zip | 06708-2761
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Country | US
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Telephone | 203-755-7748
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Fax | 203-755-7784
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Authorized Official
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Title or Position | OWNER
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Name | DR. MICHAEL GREENWALD
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Credential |
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Telephone | 203-755-7748
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number | 007481
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License Number State | CT
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