Provider Demographics
NPI:1174525497
Name:BROISMAN, LARRY B (MD)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:B
Last Name:BROISMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 KENSINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06051-3916
Mailing Address - Country:US
Mailing Address - Phone:860-832-8150
Mailing Address - Fax:860-224-6298
Practice Address - Street 1:300 KENSINGTON AVE
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06051-3916
Practice Address - Country:US
Practice Address - Phone:860-832-8150
Practice Address - Fax:860-224-6298
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT022071207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT050648OtherCONNECTICARE
CT135713OtherWELLCARE MEDICARE
CT511575OtherAETNA
CT010022071CT02OtherBCBS & BCFP PROVIDER ID
CTP369844OtherOXFORD PROVIDER ID
CT1255448155OtherGHMC GROUP NPI PROVIDER I
CTC01373OtherGHMC GROUP MEDICARE ID
CT060103OtherHEALTH NET PROVIDER ID
CT01322071OtherCIGNA PROVIDER ID
CTC01373OtherGHMC GROUP MEDICARE ID