Provider Demographics
NPI:1669865044
Name:IHSAN, SHANZA
Entity Type:Individual
Prefix:
First Name:SHANZA
Middle Name:
Last Name:IHSAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:754 CLINTON AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06604-2301
Mailing Address - Country:US
Mailing Address - Phone:203-218-1997
Mailing Address - Fax:203-923-2205
Practice Address - Street 1:46 ALBION ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06605-2602
Practice Address - Country:US
Practice Address - Phone:203-330-6000
Practice Address - Fax:203-330-6007
Is Sole Proprietor?:No
Enumeration Date:2015-03-10
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT56942207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine