=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780958884
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DISABILITY DETERMINATION SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2012
-----------------------------------------------------
Last Update Date | 03/07/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 309 WAWARME AVE
-----------------------------------------------------
City | HARTFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06114-1509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-466-6302
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20 WESTWOOD DR
-----------------------------------------------------
City | NEW BRITAIN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06052-1016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-223-4694
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL CONSULTANT
-----------------------------------------------------
Name | DR. KURSHID KHAN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 860-466-6302
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 012934
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------