Provider Demographics
NPI:1407018401
Name:SMITH, SHANNON ELIZABETH (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:ELIZABETH
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1153 CENTRE ST
Mailing Address - Street 2:SUIT 36
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02130-3446
Mailing Address - Country:US
Mailing Address - Phone:617-983-7003
Mailing Address - Fax:
Practice Address - Street 1:1153 CENTRE ST
Practice Address - Street 2:SUIT 36
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02130-3446
Practice Address - Country:US
Practice Address - Phone:617-983-7003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-30
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA251386207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology