1376925370 NPI number — SHANIQUE BINGHAM DPM

Table of content: SHANIQUE BINGHAM DPM (NPI 1376925370)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376925370 NPI number — SHANIQUE BINGHAM DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BINGHAM
Provider First Name:
SHANIQUE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376925370
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/03/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
27 HOSPITAL AVE STE 301
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DANBURY
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06810-5954
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-826-9767
Provider Business Mailing Address Fax Number:
203-826-9858

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
428 COLUMBUS AVENUE
Provider Second Line Business Practice Location Address:
PODIATRY
Provider Business Practice Location Address City Name:
NEW HAVEN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06519-1233
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-503-3070
Provider Business Practice Location Address Fax Number:
203-503-3107
Provider Enumeration Date:
06/25/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213E00000X , with the licence number: 1056 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0074725 . This is a "CSR" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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