Provider Demographics
NPI:1821177197
Name:SMITH, SHANE (DC)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 BERLIN TPKE
Mailing Address - Street 2:
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-3206
Mailing Address - Country:US
Mailing Address - Phone:860-667-8334
Mailing Address - Fax:860-760-6456
Practice Address - Street 1:2301 BERLIN TPKE
Practice Address - Street 2:
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111-3206
Practice Address - Country:US
Practice Address - Phone:860-667-8334
Practice Address - Fax:860-760-6456
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2012-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001553111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT050001553CT02OtherBLUECROSSBLUESHIELD
CT3689845OtherAETNA
CT672541OtherCONNECTICARE
CT050001553CT02OtherBLUECROSSBLUESHIELD
CT672541OtherCONNECTICARE