Provider Demographics
NPI:1255517249
Name:SAMEGULIN, IGOR (MD)
Entity type:Individual
Prefix:DR
First Name:IGOR
Middle Name:
Last Name:SAMEGULIN
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 1:74 PARK RD
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06119-1853
Mailing Address - Country:US
Mailing Address - Phone:860-218-1725
Mailing Address - Fax:860-218-1727
Practice Address - Street 1:74 PARK RD
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06119-1853
Practice Address - Country:US
Practice Address - Phone:860-218-1725
Practice Address - Fax:860-218-1727
Is Sole Proprietor?:No
Enumeration Date:2008-01-21
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT049234207Q00000X
CT49234208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008023148Medicaid