Provider Demographics
NPI:1538207295
Name:BRIDGEPORT FAMILY HEALTH LLC
Entity type:Organization
Organization Name:BRIDGEPORT FAMILY HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:J
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-371-5197
Mailing Address - Street 1:1381 RESERVOIR AVENUE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-2502
Mailing Address - Country:US
Mailing Address - Phone:203-371-5197
Mailing Address - Fax:203-371-6118
Practice Address - Street 1:1381 RESERVOIR AVENUE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-2502
Practice Address - Country:US
Practice Address - Phone:203-371-5197
Practice Address - Fax:203-371-6118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT030225207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1093715955OtherMEDICARE NPI
CT1538207295OtherGROUP NPI
CT001302257Medicaid
CT001302257Medicaid