Basic Information
| Provider Information | |||||||||
| NPI: | 1902899859 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MADRASWALLA | ||||||||
| FirstName: | AYAZ | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 WATERSIDE XING STE 401 | ||||||||
| Address2: | |||||||||
| City: | WINDSOR | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060951588 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8607315522 | ||||||||
| FaxNumber: | 8607315522 | ||||||||
| Practice Location | |||||||||
| Address1: | 391 POMFRET ST | ||||||||
| Address2: | |||||||||
| City: | PUTNAM | ||||||||
| State: | CT | ||||||||
| PostalCode: | 062601852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8607315522 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2005 | ||||||||
| LastUpdateDate: | 01/22/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 34327 | CT | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QA0401X | 034327 | CT | Y | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine |
No ID Information.