Provider Demographics
NPI:1861466328
Name:SHANNON, RICHARD DANIEL (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:DANIEL
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 1:906 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-4226
Mailing Address - Country:US
Mailing Address - Phone:970-249-2291
Mailing Address - Fax:970-240-3912
Practice Address - Street 1:906 S 4TH ST
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-4226
Practice Address - Country:US
Practice Address - Phone:970-249-2291
Practice Address - Fax:970-240-3912
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO19179208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01191790Medicaid
COD23653Medicare UPIN
COC81651Medicare ID - Type Unspecified