Individual
DR. JACK V DITEODORO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
90 MORGAN ST, SUTIE # 303, STAMFORD, CT 06905-5466
(203) 323-6873
(203) 358-9775
Mailing address
90 MORGAN ST, SUTIE # 303, STAMFORD, CT 06905-5466
(203) 323-6873
(203) 358-9775
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
035558
CT
208D00000X
General Practice Physician
035558
CT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
001355587
—
CT
01
—
1700194636
NPI
CT
Enumeration date
10/10/2006
Last updated
10/03/2010
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