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General NPI Number Information
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NPI Number | 1497774657
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Entity Type | Individual
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Provider Name | KISMATKUMAR DETROJA MD
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Gender | Male
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Dates
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Enumeration Date | 07/19/2006
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Last Update Date | 12/21/2023
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Provider Practice Location Address
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Address Line | 1000 SILVER STREET
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City | MIDDLETOWN
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State | CT
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Zip | 06457
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Country | US
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Telephone | 860-951-4954
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Fax |
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Provider Business Mailing Address
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Address Line | 170 TALCOTT RIDGE RD
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City | SOUTH WINDSOR
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State | CT
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Zip | 06074-2386
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Country | US
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Telephone | 860-794-9160
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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 | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 044462
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License Number State | CT
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