Provider Demographics
NPI:1477748648
Name:GOLDSMITH, SHANNON L (DO)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:L
Last Name:GOLDSMITH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-477-2014
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:822 MAIN ST
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MS
Practice Address - Zip Code:39437-2425
Practice Address - Country:US
Practice Address - Phone:601-477-2014
Practice Address - Fax:601-477-9942
Is Sole Proprietor?:No
Enumeration Date:2007-09-11
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34009767207Q00000X
MS24285207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07854358Medicaid
OH12114080OtherCAQH
OH3056277Medicaid
OH0236248Medicaid
MS484375YKFFMedicare PIN
OH4292131Medicare PIN
MS07854358Medicaid