Healthcare Provider Details

I. General information

NPI: 1356445415
Provider Name (Legal Business Name): LAUREL B SHADER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2006
Last Update Date: 01/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

374 GRAND AVE FAIR HAVEN COMMUNITY HEALTH CTR
NEW HAVEN CT
06513
US

IV. Provider business mailing address

535 HOWELLTON ROAD
ORANGE CT
06477
US

V. Phone/Fax

Practice location:
  • Phone: 203-777-7411
  • Fax: 203-777-8506
Mailing address:
  • Phone: 203-799-7961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number028282
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: