Provider Demographics
NPI:1154319150
Name:MANI, SHEIDA (MD)
Entity Type:Individual
Prefix:
First Name:SHEIDA
Middle Name:
Last Name:MANI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 417888
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-7888
Mailing Address - Country:US
Mailing Address - Phone:860-892-2777
Mailing Address - Fax:860-892-2772
Practice Address - Street 1:326 WASHINGTON STREET
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-2740
Practice Address - Country:US
Practice Address - Phone:860-892-2777
Practice Address - Fax:860-892-2772
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0411932085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001411933Medicaid
H82208Medicare UPIN
CT920000043Medicare ID - Type Unspecified