Provider Demographics
NPI:1174602114
Name:MALKIN, NEIL L (OD)
Entity type:Individual
Prefix:DR
First Name:NEIL
Middle Name:L
Last Name:MALKIN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 HARTFORD TPKE
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-4820
Mailing Address - Country:US
Mailing Address - Phone:860-875-9433
Mailing Address - Fax:860-871-5492
Practice Address - Street 1:375 HARTFORD TPKE
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:CT
Practice Address - Zip Code:06066-4820
Practice Address - Country:US
Practice Address - Phone:860-875-9433
Practice Address - Fax:860-871-5492
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT1008152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTT22068Medicare UPIN