=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609337302
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ADAM MASTROCOLA MD, PHD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2019
-----------------------------------------------------
Last Update Date | 09/09/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 282 WASHINGTON ST
-----------------------------------------------------
City | HARTFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06106-3322
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-545-9000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 263 FARMINGTON AVE
-----------------------------------------------------
City | FARMINGTON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06030-1921
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-679-2147
-----------------------------------------------------
Fax | 860-679-4624
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 072076
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------