MEDICARE: WATERTOWN MEDICAL ASSOCIATES, LLC

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	207R00000X	Internal Medicine Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
5	P01040202	OTHER	CT	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	049979	OTHER	CT	CONNECTICARE
2	1154493	OTHER	CT	USA
3	P4376817	OTHER	CT	OXFORD
4	5856125	OTHER	CT	CIGNA
6	05856125	OTHER	CT	GREAT WEST

General Provider Information

NPI Number	:	1063985323
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WATERTOWN MEDICAL ASSOCIATES, LLC

Provider Business Mailing Address
First Line	:	365 MAIN ST STE 201
Second Line	:
City	:	WATERTOWN
State	:	CT
Zip	:	06795-2249
Country	:	US
Telephone Number	:	860-274-2418
Fax Number	:	860-274-2986

Provider Business Practice Location Address
First Line	:	365 MAIN ST STE 201
Second Line	:
City	:	WATERTOWN
State	:	CT
Zip	:	06795-2249
Country	:	US
Telephone Number	:	860-274-2418
Fax Number	:	860-274-2986

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MAXIMILIAN GOMEZ-TROCHEZ
Credential	:	MD
Telephone Number	:	860-274-2418

Provider Enumeration Date	:	01/09/2019
Last Update Date	:	04/29/2021

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Directions to “WATERTOWN MEDICAL ASSOCIATES, LLC ” Practice Location

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