Provider Demographics
NPI:1649441999
Name:MARTHA SEVERINO MD PLLC
Entity type:Organization
Organization Name:MARTHA SEVERINO MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:Z
Authorized Official - Last Name:SEVERINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-240-4143
Mailing Address - Street 1:36 TAMARACK AVE
Mailing Address - Street 2:SUITE #322
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06811-4822
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:67 SAND PIT RD
Practice Address - Street 2:SUITE #202
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-4032
Practice Address - Country:US
Practice Address - Phone:203-778-5500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-14
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT040024207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTDE7965OtherMEDICARE RAILROAD
CTDE7965OtherMEDICARE RAILROAD