Provider Demographics
NPI:1689841520
Name:ANSONIA PODIATRY ASSOCIATES, LLC
Entity type:Organization
Organization Name:ANSONIA PODIATRY ASSOCIATES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:TRAVISANO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:203-734-4806
Mailing Address - Street 1:364 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ANSONIA
Mailing Address - State:CT
Mailing Address - Zip Code:06401-1904
Mailing Address - Country:US
Mailing Address - Phone:203-734-4806
Mailing Address - Fax:203-734-8265
Practice Address - Street 1:364 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ANSONIA
Practice Address - State:CT
Practice Address - Zip Code:06401-1904
Practice Address - Country:US
Practice Address - Phone:203-734-4806
Practice Address - Fax:203-734-8265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-09
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000678213E00000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004020517Medicaid
CT6201740001Medicare NSC