Provider Demographics
NPI:1669434049
Name:SHAHAB, ERUM (MD)
Entity type:Individual
Prefix:DR
First Name:ERUM
Middle Name:
Last Name:SHAHAB
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ELLINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06029-3360
Mailing Address - Country:US
Mailing Address - Phone:860-871-5402
Mailing Address - Fax:860-871-5413
Practice Address - Street 1:16 MAIN ST
Practice Address - Street 2:
Practice Address - City:ELLINGTON
Practice Address - State:CT
Practice Address - Zip Code:06029-3360
Practice Address - Country:US
Practice Address - Phone:860-871-5402
Practice Address - Fax:860-871-5413
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-03
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0431122084P0800X
CT04311212084A0401X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1669434049Medicaid