Provider Demographics
NPI:1275762429
Name:SHANNON, LARRY ROLAND II (MD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:ROLAND
Last Name:SHANNON
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5771 ROYAL MILE BLVD
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21801-2326
Mailing Address - Country:US
Mailing Address - Phone:410-805-7039
Mailing Address - Fax:
Practice Address - Street 1:5771 ROYAL MILE BLVD
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801-2326
Practice Address - Country:US
Practice Address - Phone:410-805-7039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-09
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.121453207T00000X
MDD72508207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery