Provider Demographics
NPI:1952177388
Name:CODLIN, SHAMYRAH
Entity Type:Individual
Prefix:
First Name:SHAMYRAH
Middle Name:
Last Name:CODLIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 CAPITOL AVE APT A
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-6200
Mailing Address - Country:US
Mailing Address - Phone:203-923-7648
Mailing Address - Fax:
Practice Address - Street 1:202 BRIDGEPORT AVE
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06460-3937
Practice Address - Country:US
Practice Address - Phone:475-422-5420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management