Provider Demographics
NPI:1891900106
Name:SHORELINE EYE ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:SHORELINE EYE ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:DISTELMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-453-3100
Mailing Address - Street 1:515 BOSTON ST
Mailing Address - Street 2:
Mailing Address - City:GUILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06437-2960
Mailing Address - Country:US
Mailing Address - Phone:203-453-3100
Mailing Address - Fax:
Practice Address - Street 1:515 BOSTON ST
Practice Address - Street 2:
Practice Address - City:GUILFORD
Practice Address - State:CT
Practice Address - Zip Code:06437-2960
Practice Address - Country:US
Practice Address - Phone:203-453-3100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT180033273OtherRAILROAD
CT180033273OtherRAILROAD
CTE10240Medicare UPIN
CTC01902Medicare ID - Type Unspecified