Provider Demographics
NPI:1497771208
Name:SHEA, RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:SHEA
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 1:56 FRANKLIN ST
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06706-1221
Mailing Address - Country:US
Mailing Address - Phone:203-709-8873
Mailing Address - Fax:203-709-8689
Practice Address - Street 1:95 SCOVILL ST
Practice Address - Street 2:3RD FLOOR
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06706-1113
Practice Address - Country:US
Practice Address - Phone:203-709-7081
Practice Address - Fax:203-709-7754
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT017418208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTE47484Medicare UPIN