Provider Demographics
NPI:1124231154
Name:TROTTER, SHANNON CAMPBELL (DO)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:CAMPBELL
Last Name:TROTTER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:SHANNON
Other - Middle Name:MAUREEN
Other - Last Name:CAMPBELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:5400 FRANTZ RD
Mailing Address - Street 2:STE 250
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43016-6102
Mailing Address - Country:US
Mailing Address - Phone:937-523-9880
Mailing Address - Fax:937-523-9899
Practice Address - Street 1:30 W MCCREIGHT AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45504-1842
Practice Address - Country:US
Practice Address - Phone:937-523-9880
Practice Address - Fax:937-523-9899
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2017-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.009495207N00000X
OH34.013026207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0052162Medicaid
OH0052162Medicaid