Healthcare Provider Details

I. General information

NPI: 1578543708
Provider Name (Legal Business Name): SIDNEY LEE SHAFRAN O. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 12/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

683 BROAD ST
BRISTOL CT
06010-6662
US

IV. Provider business mailing address

1 CROSSROADS LN
AVON CT
06001-4517
US

V. Phone/Fax

Practice location:
  • Phone: 860-583-2020
  • Fax:
Mailing address:
  • Phone: 860-404-0328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberCT803
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: