Basic Information
Provider Information
NPI: 1003016957
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MATHUR
FirstName: SHISHIR
MiddleName:  
NamePrefix: DR.
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 27 SYCAMORE ST STE 400
Address2:  
City: GLASTONBURY
State: CT
PostalCode: 060337208
CountryCode: US
TelephoneNumber: (860) 633-0500
FaxNumber: 8606335250
Practice Location
Address1: 27 SYCAMORE ST STE 400
Address2:  
City: GLASTONBURY
State: CT
PostalCode: 060337208
CountryCode: US
TelephoneNumber: (860) 633-0500
FaxNumber: 8606335250
Other Information
ProviderEnumerationDate: 07/19/2007
LastUpdateDate: 07/26/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207RC0000X047888CTY Allopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
207RI0011X047888CTN Allopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology

ID Information
IDTypeStateIssuerDescription
100301695705CT MEDICAID


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