Provider Demographics
NPI:1679553978
Name:SHANNON, JOHN D (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:D
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 1:14275 MIDWAY RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-3614
Mailing Address - Country:US
Mailing Address - Phone:972-934-4300
Mailing Address - Fax:610-271-4245
Practice Address - Street 1:4770 REGENT BLVD
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75063-2445
Practice Address - Country:US
Practice Address - Phone:972-934-4300
Practice Address - Fax:972-455-1212
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ8371207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX147415701Medicaid
TX147415701Medicaid
TXH40682Medicare UPIN
TX8188N9Medicare ID - Type Unspecified
TX8B1905Medicare ID - Type Unspecified