Provider Demographics
NPI:1760675409
Name:CONNECTICUT EYE PHYSICIANS AND SURGEONS LLC
Entity type:Organization
Organization Name:CONNECTICUT EYE PHYSICIANS AND SURGEONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER;/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:MANGANIELLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-644-5011
Mailing Address - Street 1:479 BUCKLAND RD STE A
Mailing Address - Street 2:
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-3739
Mailing Address - Country:US
Mailing Address - Phone:860-644-5011
Mailing Address - Fax:860-644-4833
Practice Address - Street 1:479 BUCKLAND RD
Practice Address - Street 2:
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-3739
Practice Address - Country:US
Practice Address - Phone:860-644-5011
Practice Address - Fax:860-644-4833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-27
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT035387207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001353870Medicaid
CTG27130Medicare UPIN