Provider Demographics
NPI:1497741243
Name:SOPP, SHANE M (MD)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:M
Last Name:SOPP
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2003
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-4503
Mailing Address - Country:US
Mailing Address - Phone:315-446-3904
Mailing Address - Fax:315-445-2936
Practice Address - Street 1:4900 BROAD RD
Practice Address - Street 2:CGH POB SUITE 2V
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13215-2265
Practice Address - Country:US
Practice Address - Phone:315-492-5005
Practice Address - Fax:315-492-5324
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY141803207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B82144Medicare UPIN
160044866Medicare PIN