Provider Demographics
NPI:1225491152
Name:MAZUR, SHANNON LOUISE DONOVAN (DO)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:LOUISE DONOVAN
Last Name:MAZUR
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:SHANNON
Other - Middle Name:LOUISE
Other - Last Name:DONOVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:20 YORK ST
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-3220
Mailing Address - Country:US
Mailing Address - Phone:203-688-4242
Mailing Address - Fax:
Practice Address - Street 1:20 YORK ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3220
Practice Address - Country:US
Practice Address - Phone:203-688-4242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-29
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA267966390200000X
CT66655390200000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program