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General NPI Number Information
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NPI Number | 1598887218
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Entity Type | Individual
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Provider Name | MARC N POTENZA MD PHD
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Gender | Male
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Dates
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Enumeration Date | 04/04/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 2 VANCE DRIVE CONNECTICUT VALLEY HOSPITAL PROBLEM GAMBLING SERVICES R
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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 | 860-344-2244
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Fax | 860-344-2360
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Provider Business Mailing Address
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Address Line | PO BOX 351 2 VANCE DRIVE CONNECTICUT VALLEY HOSPITAL PROBLEM GAMBL
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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 | 860-344-2244
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Fax | 860-344-2360
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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 | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 035340
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License Number State | CT
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