Provider Demographics
NPI:1518153261
Name:SMITH, SHANNON JANINE (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:JANINE
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 1:1776 WOODSTEAD CT STE 208
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77380-1480
Mailing Address - Country:US
Mailing Address - Phone:877-749-7428
Mailing Address - Fax:512-628-3314
Practice Address - Street 1:2701 N DECATUR RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-5918
Practice Address - Country:US
Practice Address - Phone:877-749-7428
Practice Address - Fax:512-628-3314
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-17
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA066325208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1518153261OtherNPI
MSP00628027OtherRAILROAD PROVIDER NO.
MS09852052Medicaid
MSP00628027OtherRAILROAD PROVIDER NO.