Healthcare Provider Details

I. General information

NPI: 1861600165
Provider Name (Legal Business Name): DEREK S SHIA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 04/27/2022
Certification Date: 04/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 WASHINGTON AVE FL 1A
HAMDEN CT
06518-3267
US

IV. Provider business mailing address

2408 WHITNEY AVE
HAMDEN CT
06518-3209
US

V. Phone/Fax

Practice location:
  • Phone: 203-865-6784
  • Fax: 203-865-6788
Mailing address:
  • Phone: 203-626-0160
  • Fax: 203-626-0160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number50534
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number50534
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: