Provider Demographics
NPI:1265598130
Name:JANDALI, SHAREEF (MD)
Entity type:Individual
Prefix:
First Name:SHAREEF
Middle Name:
Last Name:JANDALI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5520 PARK AVE
Mailing Address - Street 2:SUITE WP-2-300
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-3463
Mailing Address - Country:US
Mailing Address - Phone:203-374-0310
Mailing Address - Fax:203-374-0314
Practice Address - Street 1:5520 PARK AVE
Practice Address - Street 2:SUITE WP-2-300
Practice Address - City:TRUMBULL
Practice Address - State:CT
Practice Address - Zip Code:06611-3463
Practice Address - Country:US
Practice Address - Phone:203-374-0310
Practice Address - Fax:203-374-0314
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0495382086S0122X
PAMT185935208200000X
CTMD 049538208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery