Provider Demographics
NPI:1710935192
Name:MOBLEY, SHANNON VERNNON (DO)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:VERNNON
Last Name:MOBLEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:532 1ST ST NW
Mailing Address - Street 2:
Mailing Address - City:BRITT
Mailing Address - State:IA
Mailing Address - Zip Code:50423-1227
Mailing Address - Country:US
Mailing Address - Phone:641-843-5000
Mailing Address - Fax:
Practice Address - Street 1:532 1ST ST NW
Practice Address - Street 2:
Practice Address - City:BRITT
Practice Address - State:IA
Practice Address - Zip Code:50423-1227
Practice Address - Country:US
Practice Address - Phone:641-843-5050
Practice Address - Fax:641-843-5051
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101014250207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4573316Medicaid
MIN15380-008Medicare ID - Type Unspecified
MIH63543Medicare UPIN