Provider Demographics
NPI:1730235789
Name:HERATH, SHIROMINI (MD)
Entity type:Individual
Prefix:
First Name:SHIROMINI
Middle Name:
Last Name:HERATH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 GRAND ST
Mailing Address - Street 2:
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06052-2016
Mailing Address - Country:US
Mailing Address - Phone:860-224-5305
Mailing Address - Fax:860-224-5565
Practice Address - Street 1:100 GRAND ST
Practice Address - Street 2:MEDICAL STAFF OFFICE ATTN ONDREA CHASSE
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06052-2016
Practice Address - Country:US
Practice Address - Phone:860-224-5305
Practice Address - Fax:860-224-5565
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT045058207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT045058OtherLIC