Basic Information
| Provider Information | |||||||||
| NPI: | 1629041744 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHEARES | ||||||||
| FirstName: | BEVERLEY | ||||||||
| MiddleName: | JEANNE | ||||||||
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| Credential: | MD, MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 CEDAR STREET | ||||||||
| Address2: | PO BOX 208064, LMP3096A | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 0327852480 | ||||||||
| FaxNumber: | 2037856337 | ||||||||
| Practice Location | |||||||||
| Address1: | 333 CEDAR ST | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 0327852480 | ||||||||
| FaxNumber: | 2037856337 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2006 | ||||||||
| LastUpdateDate: | 06/29/2018 | ||||||||
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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 | 2080P0214X | 182028 | NY | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Pulmonology | 2080P0214X | 60460 | CT | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Pulmonology |
ID Information
| ID | Type | State | Issuer | Description | 01187719 | 05 | NY | MEDICAID |