Basic Information
| Provider Information | |||||||||
| NPI: | 1356445415 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | SHADER | ||||||||
| FirstName: | LAUREL | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 535 HOWELLTON ROAD | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037997961 | ||||||||
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| Practice Location | |||||||||
| Address1: | 374 GRAND AVE | ||||||||
| Address2: | FAIR HAVEN COMMUNITY HEALTH CTR | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037777411 | ||||||||
| FaxNumber: | 2037778506 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2006 | ||||||||
| LastUpdateDate: | 01/29/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 028282 | CT | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 004235736 | 01 | COMMUNITY HEALTH NETWORK | OTHER | 5175619 | 01 | CIGNA | OTHER | 1051526 | 01 | AETNA US HEALTHCARE | OTHER | 0282829734 | 01 | CONNECTICARE | OTHER | P473785 | 01 | OXFORD | OTHER | 004235736 | 05 | CT | MEDICAID | 010028282CT03 | 01 | ANTHEM BCBS | OTHER |