Provider Demographics
NPI:1548359060
Name:ANCONA, JOHN P (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:P
Last Name:ANCONA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1527 ROUTE 12
Mailing Address - Street 2:PO BOX 608
Mailing Address - City:GALES FERRY
Mailing Address - State:CT
Mailing Address - Zip Code:06335-1800
Mailing Address - Country:US
Mailing Address - Phone:860-464-7248
Mailing Address - Fax:860-464-0125
Practice Address - Street 1:1527 ROUTE 12
Practice Address - Street 2:
Practice Address - City:GALES FERRY
Practice Address - State:CT
Practice Address - Zip Code:06335-1800
Practice Address - Country:US
Practice Address - Phone:860-464-7248
Practice Address - Fax:860-464-0125
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT041171208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
041171OtherCONNECTICARE
010041171CT01OtherBLUE CROSS
CT01411719Medicaid
041171OtherCIGNA
2V4776OtherHEALTHNET
041171OtherCONNECTICARE