Healthcare Provider Details

I. General information

NPI: 1265598130
Provider Name (Legal Business Name): SHAREEF JANDALI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 10/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5520 PARK AVE SUITE WP-2-300
TRUMBULL CT
06611-3463
US

IV. Provider business mailing address

5520 PARK AVE SUITE WP-2-300
TRUMBULL CT
06611-3463
US

V. Phone/Fax

Practice location:
  • Phone: 203-374-0310
  • Fax: 203-374-0314
Mailing address:
  • Phone: 203-374-0310
  • Fax: 203-374-0314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberMT185935
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberMD 049538
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number049538
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: