Provider Demographics
NPI:1669685079
Name:SHANNON, KAREN CHILD (MD)
Entity Type:Individual
Prefix:DR
First Name:KAREN
Middle Name:CHILD
Last Name:SHANNON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25455 BARTON RD STE 206A
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3130
Mailing Address - Country:US
Mailing Address - Phone:909-558-6600
Mailing Address - Fax:
Practice Address - Street 1:25455 BARTON RD STE 206A
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3130
Practice Address - Country:US
Practice Address - Phone:909-558-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG89216207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30201593Medicaid
NHE80721Medicare UPIN
NHRE6474Medicare PIN