Provider Demographics
NPI:1427329416
Name:SEDAT S. SHABAN, M.D.,P.C.
Entity type:Organization
Organization Name:SEDAT S. SHABAN, M.D.,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SEDAT
Authorized Official - Middle Name:SELAJDIN
Authorized Official - Last Name:SHABAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-755-1464
Mailing Address - Street 1:1389 W MAIN ST
Mailing Address - Street 2:SUITE 308
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-3104
Mailing Address - Country:US
Mailing Address - Phone:203-755-1464
Mailing Address - Fax:203-754-7721
Practice Address - Street 1:1389 W MAIN ST
Practice Address - Street 2:SUITE 308
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-3104
Practice Address - Country:US
Practice Address - Phone:203-755-1464
Practice Address - Fax:203-754-7721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-23
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT019493208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001194935Medicaid
CT001194935Medicaid