Provider Demographics
NPI:1477547099
Name:LIVINGSTON, SHANNON S (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:S
Last Name:LIVINGSTON
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 1:138 HWY 46 W
Mailing Address - Street 2:
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006-3332
Mailing Address - Country:US
Mailing Address - Phone:830-630-9020
Mailing Address - Fax:830-331-8586
Practice Address - Street 1:138 HWY 46 W
Practice Address - Street 2:
Practice Address - City:BOERNE
Practice Address - State:TX
Practice Address - Zip Code:78006
Practice Address - Country:US
Practice Address - Phone:830-630-9020
Practice Address - Fax:830-626-9037
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-09
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM0330207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXI10979Medicare UPIN