Provider Demographics
NPI:1629005368
Name:SHANNON, KEVIN MICHEAL (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:MICHEAL
Last Name:SHANNON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10833 LE CONTE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-3075
Mailing Address - Country:US
Mailing Address - Phone:310-825-5296
Mailing Address - Fax:310-825-9524
Practice Address - Street 1:10833 LE CONTE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-3075
Practice Address - Country:US
Practice Address - Phone:310-825-5296
Practice Address - Fax:310-825-9524
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG640232080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G640230Medicaid
CAWG64023BMedicare PIN
CAGZ515ZMedicare PIN