MEDICARE: DR. ERIC L WASSERMAN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	028681	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	180000379	OTHER	CT	PTAN

General Provider Information

NPI Number	:	1023016011
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ERIC L WASSERMAN M.D.

Provider Business Mailing Address
First Line	:	1275 SUMMER ST
Second Line	:	SUITE 200
City	:	STAMFORD
State	:	CT
Zip	:	06905-5359
Country	:	US
Telephone Number	:	203-978-0800
Fax Number	:	203-674-8519

Provider Business Practice Location Address
First Line	:	1275 SUMMER ST
Second Line	:	SUITE 200
City	:	STAMFORD
State	:	CT
Zip	:	06905-5359
Country	:	US
Telephone Number	:	203-978-0800
Fax Number	:	203-674-8519

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/13/2005
Last Update Date	:	01/15/2013

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