Provider Demographics
NPI:1912135211
Name:BAO, SHANSHAN (MD)
Entity Type:Individual
Prefix:
First Name:SHANSHAN
Middle Name:
Last Name:BAO
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 1:111 FOUNDERS PLAZA
Mailing Address - Street 2:STE 400
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108
Mailing Address - Country:US
Mailing Address - Phone:860-289-3375
Mailing Address - Fax:860-783-5733
Practice Address - Street 1:85 SEYMOUR ST STE 200
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-5509
Practice Address - Country:US
Practice Address - Phone:860-246-6589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-24
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1286672085R0202X
MA2707492085R0202X
CT563092085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology