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General NPI Number Information
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NPI Number | 1497094924
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Entity Type | Individual
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Provider Name | FREDERIC TAYLOR MAUCK M.D.
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Gender | Male
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Dates
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Enumeration Date | 02/04/2013
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Last Update Date | 02/06/2013
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Provider Practice Location Address
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Address Line | 12 PORTER RD
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City | FARMINGTON
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State | CT
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Zip | 06032-2221
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Country | US
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Telephone | 860-677-2474
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Fax |
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Provider Business Mailing Address
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Address Line | 12 PORTER ROAD
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City | FARMINGTON
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State | CT
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Zip | 06032
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Country | US
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Telephone | 860-677-2474
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 011113
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License Number State | CT
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