Provider Demographics
NPI:1558472779
Name:WALSH, SHANNON KAREEN (DO)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:KAREEN
Last Name:WALSH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:CHEFFET
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:FILE 57326
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-7326
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 W ARBOR DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-9000
Practice Address - Country:US
Practice Address - Phone:800-926-8273
Practice Address - Fax:888-539-8781
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8617208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACX058WOtherPTAN
CAW12026OtherGROUP PTAN