Provider Demographics
NPI:1730399411
Name:DOMENIC W. CASABLANCA, M.D., P.C.
Entity type:Organization
Organization Name:DOMENIC W. CASABLANCA, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOMENIC
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:CASABLANCA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-225-0375
Mailing Address - Street 1:4 CORPORATE DR
Mailing Address - Street 2:SUITE 195
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-6211
Mailing Address - Country:US
Mailing Address - Phone:203-225-0375
Mailing Address - Fax:203-225-0376
Practice Address - Street 1:4 CORPORATE DR
Practice Address - Street 2:SUITE 195
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484-6211
Practice Address - Country:US
Practice Address - Phone:203-225-0375
Practice Address - Fax:203-225-0376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTDC4029OtherMEDICARE RAILROAD
CTC02919Medicare ID - Type Unspecified