Provider Demographics
NPI:1548757800
Name:SHANNON, LOGAN T (DPM)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:T
Last Name:SHANNON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:943 S BENEVA RD STE 306
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34232-2499
Mailing Address - Country:US
Mailing Address - Phone:941-955-1108
Mailing Address - Fax:941-954-4440
Practice Address - Street 1:943 S BENEVA RD STE 113
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34232-2471
Practice Address - Country:US
Practice Address - Phone:941-316-0133
Practice Address - Fax:941-957-3641
Is Sole Proprietor?:No
Enumeration Date:2018-04-21
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103301320213E00000X, 213ES0131X
FLPO4392213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery