Provider Demographics
NPI:1528018157
Name:MULLIGAN, SHANNON M (OD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:M
Last Name:MULLIGAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87 GRANDVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2514
Mailing Address - Country:US
Mailing Address - Phone:203-574-2020
Mailing Address - Fax:203-596-2230
Practice Address - Street 1:604 LAKEWOOD RD
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06704-2419
Practice Address - Country:US
Practice Address - Phone:203-575-0900
Practice Address - Fax:203-573-9894
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002345152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U72193Medicare UPIN