Provider Demographics
NPI:1477518793
Name:SHANN, TIMOTHY RAY (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:RAY
Last Name:SHANN
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 1:509 BROOKMAN DR
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601-2326
Mailing Address - Country:US
Mailing Address - Phone:601-823-5204
Mailing Address - Fax:601-833-1224
Practice Address - Street 1:509 BROOKMAN DR
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-2326
Practice Address - Country:US
Practice Address - Phone:601-823-5204
Practice Address - Fax:601-833-1224
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK21817208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK731310891006OtherUNICARE
OK731310891028OtherTRICARE SOUTH
OK100253110AMedicaid
OK100253110AOtherSOONER PCP
OK74502A041OtherCHAMPUS (WPS)
OK731310891028OtherTRICARE SOUTH