Provider Demographics
NPI:1518971225
Name:SHANNON, FREDERICK BRETT (DO)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:BRETT
Last Name:SHANNON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15880 SUMMERLIN RD
Mailing Address - Street 2:STE 300 PMB 322
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-9612
Mailing Address - Country:US
Mailing Address - Phone:239-432-5100
Mailing Address - Fax:239-432-0629
Practice Address - Street 1:15821 HOLLYFERN CT
Practice Address - Street 2:
Practice Address - City:FT. MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908
Practice Address - Country:US
Practice Address - Phone:239-432-5100
Practice Address - Fax:239-432-0629
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS4993207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL372036500Medicaid
FL2017372-007OtherCIGNA
FL4283415OtherAETNA
FL80729OtherBLUE CROSS BLUE SHIELD
FL207270OtherAVMED
FL195066OtherAMERIGROUP
FL16065OtherSTAYWELL HEALTHY KIDS
FL195066OtherAMERIGROUP