Provider Demographics
NPI:1689781841
Name:SHANNON, THOMAS OSWALD (MD)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:OSWALD
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 1:3115 COLLEGE PARK DRIVE
Mailing Address - Street 2:STE 101
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77384-4001
Mailing Address - Country:US
Mailing Address - Phone:936-321-4345
Mailing Address - Fax:936-321-4353
Practice Address - Street 1:3115 COLLEGE PARK DRIVE
Practice Address - Street 2:STE 101
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77384-4001
Practice Address - Country:US
Practice Address - Phone:936-321-4345
Practice Address - Fax:936-321-4353
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ50142086S0122X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX080725701Medicaid
TX139377915Medicaid
TX080725701Medicaid
TX4638008OtherCIGNA
E77804Medicare UPIN
TX080725701Medicaid