Provider Demographics
NPI:1639134232
Name:MARTINELLO, SHANNON P (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:P
Last Name:MARTINELLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 WHITNEY AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-7204
Mailing Address - Country:US
Mailing Address - Phone:203-397-1243
Mailing Address - Fax:203-397-1241
Practice Address - Street 1:303 WHITNEY AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-7204
Practice Address - Country:US
Practice Address - Phone:203-397-1243
Practice Address - Fax:203-397-1241
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT37763208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001377630Medicaid
CT001377630Medicaid