Provider Demographics
NPI:1356470314
Name:SHANNON, KEVIN CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:CHARLES
Last Name:SHANNON
Suffix:
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 1:1454 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-0118
Mailing Address - Country:US
Mailing Address - Phone:909-382-7146
Mailing Address - Fax:909-382-7101
Practice Address - Street 1:1454 E 2ND ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-0118
Practice Address - Country:US
Practice Address - Phone:909-382-7146
Practice Address - Fax:909-382-7101
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2013-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH11096207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30201226Medicaid
VT0RE6020Medicaid
NH30201226Medicaid
NHRE602001Medicare PIN