Provider Demographics
NPI:1528371895
Name:HALLOWELL, SHOSHANA DEANN (MD)
Entity Type:Individual
Prefix:
First Name:SHOSHANA
Middle Name:DEANN
Last Name:HALLOWELL
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 1:1400 SE GOLDTREE DR
Mailing Address - Street 2:SUITE 102-104
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-7582
Mailing Address - Country:US
Mailing Address - Phone:772-335-8446
Mailing Address - Fax:772-335-8499
Practice Address - Street 1:29000 LITTLE MACK AVE STE B
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-3018
Practice Address - Country:US
Practice Address - Phone:586-774-8811
Practice Address - Fax:586-541-0199
Is Sole Proprietor?:No
Enumeration Date:2010-07-15
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME126441208600000X
MI4301500635208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery