Healthcare Provider Details

I. General information

NPI: 1013477538
Provider Name (Legal Business Name): TIMOTHY DANIEL SHUB MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2019
Last Update Date: 10/11/2022
Certification Date: 10/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 MAPLE ST
NORWALK CT
06850-3894
US

IV. Provider business mailing address

1706 BUSHWICK AVE
MERRICK NY
11566-2938
US

V. Phone/Fax

Practice location:
  • Phone: 203-852-2000
  • Fax:
Mailing address:
  • Phone: 347-277-3691
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number69607
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: