=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972636793
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEW LONDON FAMILY PRACTICE, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4 SHAWS CV SUITE 103
-----------------------------------------------------
City | NEW LONDON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06320-4956
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-443-3778
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4 SHAWS CV SUITE 103
-----------------------------------------------------
City | NEW LONDON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06320-4956
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-443-3778
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER
-----------------------------------------------------
Name | DR. STEVEN P JOHNSON
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 860-443-3778
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 027140
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------