Unknown Individual – Family Medicine Physician, NPI 1053390500

Unknown Individual is a healthcare provider. based in Willimantic, Connecticut. specializing in Family Medicine Physician. They hold a License No. 011894 (CT). The NPI Number for Unknown Individual is 1053390500

Main info

Organization
Inactive
65 Years Of Experience
Accepts Medicare Assignment
Name
Unknown Individual
NPI
1053390500
Phone
(860) 450-7471
Address
40 MANSFIELD AVE
Deactivation Date
19 June 2025

Doctor Profile

Medical School Name
STATE UNIVERSITY OF NEW YORK DOWNSTATE MEDICAL CENTER
Secondary Phone
8604507471
Graduation Year
1961 (65 years ago)
PAC ID
5698848331
Group Practice PAC ID
4880640630
Professional Enrollment ID
I20080714000643
Data current as of
19 May 2026

Profile Insights

NPPES metrics only — not quality of care.

Methodology
Experience14
Completeness75
Years active:0State licenses:1Digital endpointsOther names

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Provider Addresses for Unknown Individual

  • Generations Family Health Center, 40, Mansfield Avenue, Willimantic, Windham, Windham County, Connecticut, 06226, United States

    WILLIMANTIC, CT 062262018

    Phone: (860) 450-7471

    Mailing address matches the actual address.

NPPES updates history

No NPPES updates recorded for this provider.

Prescription Activity

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Open Payments (CMS)

No Open Payments data available for this provider.

This can happen when there are no reportable CMS Open Payments records.

Medicare Enrollment & Revalidation

Source: CMS public data · Not endorsed by CMS ·

Educational use only—not medical, billing, or legal advice.

No Medicare enrollment or revalidation data available for this provider in our database.

Prepare CMS-855 application → · Look up this NPI in PECOS → · Verify on CMS PECOS

Medicare Utilization (FFS)

Source: CMS public data · Not endorsed by CMS · Beneficiary counts under 11 are suppressed in source data ·

Educational use only—not medical, billing, or legal advice.

No Medicare fee-for-service utilization data available for this provider in our database.

Insurance plans in this area (ZIP 06226)

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Group practice members

Group practice members are other physicians who share the same Group Practice PAC ID with this doctor. When doctors form a group practice and register in PECOS as a single entity, they receive a shared identification number. This table lists all providers in the same group practice.
PAC ID: 4880640630View full group profile

Reviews

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Frequently asked questions

What number should I use to identify Unknown Individual for billing?
Administrative and clinical systems typically use NPI 1053390500 for Unknown Individual.
What should I verify if Unknown Individual is listed inactive?
If Unknown Individual looks inactive here, cross-check state licensing and the clinic website.
What type of care does Unknown Individual provide?
Unknown Individual's profile centers on Family Medicine Physician. Clinical services aligned with this taxonomy classification.
Can patients visit Unknown Individual in Willimantic, Connecticut?
For routing, start with Willimantic, Connecticut for Unknown Individual, then verify phone and hours locally.
Who maintains Unknown Individual's record?
Providers certify NPPES data; CMS hosts the public file you are viewing.

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