Provider Demographics
NPI:1659445732
Name:SHANNON, NATALYA (MD)
Entity Type:Individual
Prefix:
First Name:NATALYA
Middle Name:
Last Name:SHANNON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:NATALYA
Other - Middle Name:
Other - Last Name:SEYFETDINOVA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2021 N MACARTHUR BLVD
Mailing Address - Street 2:STE 150
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75061-2219
Mailing Address - Country:US
Mailing Address - Phone:972-253-2560
Mailing Address - Fax:972-253-4218
Practice Address - Street 1:2021 N MACARTHUR BLVD
Practice Address - Street 2:STE 250
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75061-2219
Practice Address - Country:US
Practice Address - Phone:972-253-4340
Practice Address - Fax:972-253-4328
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM1339208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX178348202Medicaid
TX1783482Medicaid
TX1783482Medicaid
TX178348202Medicaid