Provider Demographics
NPI:1497730345
Name:SHAYWITZ, BENNETT A (MD)
Entity Type:Individual
Prefix:
First Name:BENNETT
Middle Name:A
Last Name:SHAYWITZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 YORK ST
Mailing Address - Street 2:YNHH CHILDREN'S HOSPITAL, WEST PAVILION, 2ND FLOOR
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-3220
Mailing Address - Country:US
Mailing Address - Phone:203-785-4081
Mailing Address - Fax:203-785-5383
Practice Address - Street 1:20 YORK ST
Practice Address - Street 2:YNHH CHILDREN'S HOSPITAL, WEST PAVILION, 2ND FLOOR
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3220
Practice Address - Country:US
Practice Address - Phone:203-785-4081
Practice Address - Fax:203-785-5383
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0157652084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001157650Medicaid
CT370000330Medicare ID - Type Unspecified
CT001157650Medicaid