Provider Demographics
NPI:1457415648
Name:SHABAN, SEDAT SELAJDIN
Entity Type:Individual
Prefix:DR
First Name:SEDAT
Middle Name:SELAJDIN
Last Name:SHABAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1389 WEST MAIN ST
Mailing Address - Street 2:STE 308
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708
Mailing Address - Country:US
Mailing Address - Phone:203-755-1464
Mailing Address - Fax:
Practice Address - Street 1:1389 WEST MAIN ST
Practice Address - Street 2:STE 308
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708
Practice Address - Country:US
Practice Address - Phone:203-755-1464
Practice Address - Fax:203-754-7721
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT19493208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001194935Medicaid
CT001194935Medicaid