The Dermatology Center of Connecticut, LLC

Primary specialty

Dermatology PhysicianTaxonomy code 207N00000X

Legal business name

THE DERMATOLOGY CENTER OF CONNECTICUT, LLC

Practice address

60 Church St Unit 4B
Wallingford, CT 06492-2340

Phone

(203) 907-8474

NPI assigned

Mar 6, 2020

Organization subpart

No

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

Authorized official

Name

Kimberly Ellen BoldonNPI 1083083638

Title

Owner

Phone

(203) 907-8474

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in CT

Enrollment records 1

Locations

Practitioners 3

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

• Kimberly Ellen Boldon, NP-C

  • Nurse Practitioner
  • Middletown, CT
  • NPI 1083083638
  Medicare reassignment Care Compare group NPD Authorized official
• Gregory Jarvis Rau, P.A.

  • Medical Physician Assistant
  • New Haven, CT
  • NPI 1528006038
  Medicare reassignment Care Compare group
• Dana Ellis, M.D.

  • Dermatology Physician
  • Lakewood Ranch, FL
  • NPI 1902171341

  CT

  Medicare reassignment NPD

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

{
    "created_epoch": "1583452800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1583452800000",
    "number": "1922633213",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1790 CHESHIRE ST",
            "city": "CHESHIRE",
            "state": "CT",
            "postal_code": "064101237"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "60 CHURCH ST UNIT 4B",
            "city": "WALLINGFORD",
            "state": "CT",
            "postal_code": "064922340",
            "telephone_number": "203-907-8474"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "THE DERMATOLOGY CENTER OF CONNECTICUT, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-03-06",
        "last_updated": "2020-03-06",
        "certification_date": "2020-03-06",
        "status": "A",
        "authorized_official_last_name": "BOLDON",
        "authorized_official_first_name": "KIMBERLY",
        "authorized_official_middle_name": "ELLEN",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "203-907-8474"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dermatology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Silvia Taveras
• Jackson Taylor
• Michelle Renee Taylor, M.D.
• Technical Gas Products Inc
• The Center for Foot and Ankle Surgery, LLC
• The Promptcare Companies, Inc.
• The Stop & Shop Supermarket Company, LLC
• The Women'S Center of Southern New England, LLC
• The Young Men'S Christian Association of Wallingford, Incorporated
• Therapy for Language and Communication, LLC

• Dermatology Physician in Wallingford, CT
• Providers in Wallingford, CT by specialty
• Dermatology Physician in Connecticut

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 6, 2020; 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.