Provider Demographics
NPI:1255659637
Name:JONES, SHANNON MARY (MD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARY
Last Name:JONES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:MARY
Other - Last Name:FULLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:507 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-1810
Mailing Address - Country:US
Mailing Address - Phone:607-763-8008
Mailing Address - Fax:607-763-8019
Practice Address - Street 1:507 MAIN ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-1810
Practice Address - Country:US
Practice Address - Phone:607-763-8008
Practice Address - Fax:607-763-8019
Is Sole Proprietor?:No
Enumeration Date:2010-05-11
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY271464207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03726212Medicaid