Provider Demographics
NPI:1598876237
Name:SMITH, SHANNON L (MD FACS)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:L
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD FACS
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3302 NE STALLINGS DR
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965-8727
Mailing Address - Country:US
Mailing Address - Phone:936-564-3600
Mailing Address - Fax:936-564-3770
Practice Address - Street 1:3302 NE STALLINGS DR
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-8727
Practice Address - Country:US
Practice Address - Phone:936-564-3600
Practice Address - Fax:936-564-3770
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH2797207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8BB470OtherBCBS
TX127607302Medicaid
TX00Y956OtherMEDICARE GROUP
TX8F7718OtherMEDICARE ID; TYPE UNSPECIFIED
F32219Medicare UPIN