Organization
JACK V. DITEODORO M.D,LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JACK V DITEODORO M.D. (OWNER)
(203) 323-6873
Entity
Organization
Contact information
Practice address
90 MORGAN STEET STUITE 303, STAMFORD, CT 06905-5436
(203) 323-6873
Mailing address
90 MORGAN ST STE 303, STAMFORD, CT 06905-5436
(203) 323-6873
Taxonomy
Speciality
Code
Description
License number
State
302F00000X
Exclusive Provider Organization
035558
CT
302R00000X
Health Maintenance Organization
035558
CT
305R00000X
Preferred Provider Organization
035558
CT
305S00000X
Point of Service
Primary
035558
CT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
001355587
—
CT
Enumeration date
09/14/2010
Last updated
09/14/2010
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