NPIMap

Organization Active NPI

Jack V. Diteodoro M.D,LLC

  • Point of Service
  • Stamford, CT
National Provider Identifier
1700194636
Registry record updated Sep 14, 2010
On this page

Key facts

NPPES NPI Registry
Primary specialty
Point of ServiceTaxonomy code 305S00000X
License
035558 Issued in CT
Legal business name
JACK V. DITEODORO M.D,LLC
Practice address
90 Morgan Steet Stuite 303
Stamford, CT 06905-5436
Phone
(203) 323-6873
NPI assigned
Sep 14, 2010
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 14, 2010

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Jack V Diteodoro, M.D.NPI 1346338837
Title
Owner
Phone
(203) 323-6873

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Exclusive Provider Organization 302F00000X 035558 CT
Health Maintenance Organization 302R00000X 035558 CT
Preferred Provider Organization 305R00000X 035558 CT
Point of Service 305S00000X 035558 CT Primary

Addresses

Primary practice location

90 Morgan Steet Stuite 303
Stamford, CT 06905-5436

Mailing address

90 Morgan St Ste 303
Stamford, CT 06905-5436
Phone (203) 323-6873

Other identifiers 1

IdentifierTypeStateIssuer
001355587MedicaidCT

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CT

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20120307000020 CT Part B Supplier - Clinic/Group Practice 8729247077 Receives reassigned benefits from 5 practitioners
Practice locations: Stamford, CT

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 5

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1284422400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1284422400000",
    "number": "1700194636",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "90 MORGAN ST STE 303",
            "city": "STAMFORD",
            "state": "CT",
            "postal_code": "069055436",
            "telephone_number": "203-323-6873"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "90 MORGAN STEET STUITE 303",
            "city": "STAMFORD",
            "state": "CT",
            "postal_code": "069055436",
            "telephone_number": "203-323-6873"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "JACK V. DITEODORO M.D,LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2010-09-14",
        "last_updated": "2010-09-14",
        "status": "A",
        "authorized_official_last_name": "DITEODORO",
        "authorized_official_first_name": "JACK",
        "authorized_official_middle_name": "V",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "203-323-6873",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "302F00000X",
            "taxonomy_group": "",
            "desc": "Exclusive Provider Organization",
            "state": "CT",
            "license": "035558",
            "primary": false
        },
        {
            "code": "302R00000X",
            "taxonomy_group": "",
            "desc": "Health Maintenance Organization",
            "state": "CT",
            "license": "035558",
            "primary": false
        },
        {
            "code": "305R00000X",
            "taxonomy_group": "",
            "desc": "Preferred Provider Organization",
            "state": "CT",
            "license": "035558",
            "primary": false
        },
        {
            "code": "305S00000X",
            "taxonomy_group": "",
            "desc": "Point of Service",
            "state": "CT",
            "license": "035558",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "001355587",
            "state": "CT"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Stamford, CT

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 14, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.