Provider Demographics
NPI:1710187505
Name:JOHN W. EDELGLASS M.D., P.C.
Entity type:Organization
Organization Name:JOHN W. EDELGLASS M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:WARREN
Authorized Official - Last Name:EDELGLASS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-389-1185
Mailing Address - Street 1:1 BRADLEY RD
Mailing Address - Street 2:SUITE 705
Mailing Address - City:WOODBRIDGE
Mailing Address - State:CT
Mailing Address - Zip Code:06525-2285
Mailing Address - Country:US
Mailing Address - Phone:203-389-1185
Mailing Address - Fax:203-389-1427
Practice Address - Street 1:1 BRADLEY RD
Practice Address - Street 2:SUITE 705
Practice Address - City:WOODBRIDGE
Practice Address - State:CT
Practice Address - Zip Code:06525-2285
Practice Address - Country:US
Practice Address - Phone:203-389-1185
Practice Address - Fax:203-389-1427
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-20
Last Update Date:2007-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT023280207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC00153OtherMEDICARE GROUP