Provider Demographics
NPI:1376925370
Name:BINGHAM, SHANIQUE (DPM)
Entity Type:Individual
Prefix:
First Name:SHANIQUE
Middle Name:
Last Name:BINGHAM
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 HOSPITAL AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-5954
Mailing Address - Country:US
Mailing Address - Phone:203-826-9767
Mailing Address - Fax:203-826-9858
Practice Address - Street 1:428 COLUMBUS AVENUE
Practice Address - Street 2:PODIATRY
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1233
Practice Address - Country:US
Practice Address - Phone:203-503-3070
Practice Address - Fax:203-503-3107
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-25
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT1056213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0074725OtherCSR