Provider Demographics
NPI:1366976524
Name:O'BRIEN, SHANE (MD)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:O'BRIEN
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 1:1455 E RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621-2006
Mailing Address - Country:US
Mailing Address - Phone:585-922-2575
Mailing Address - Fax:585-922-5033
Practice Address - Street 1:1455 E RIDGE RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-2006
Practice Address - Country:US
Practice Address - Phone:585-922-2575
Practice Address - Fax:585-922-5033
Is Sole Proprietor?:No
Enumeration Date:2017-04-14
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY303137208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics