Provider Demographics
NPI:1083788681
Name:RUSH, SHANNON M (DPM)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:M
Last Name:RUSH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4626 WILLOW RD
Mailing Address - Street 2:STE 200
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94588-8564
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 E EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:SUNNYVALE
Practice Address - State:CA
Practice Address - Zip Code:94040
Practice Address - Country:US
Practice Address - Phone:650-934-7090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4271213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U80857Medicare UPIN