Provider Demographics
NPI:1922368331
Name:STEVENSON, SHANNON L (DO)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:L
Last Name:STEVENSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 ACKERMAN RD STE 2120
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1559
Mailing Address - Country:US
Mailing Address - Phone:614-293-5123
Mailing Address - Fax:
Practice Address - Street 1:3691 RIDGE MILL DR
Practice Address - Street 2:
Practice Address - City:HILLIARD
Practice Address - State:OH
Practice Address - Zip Code:43026
Practice Address - Country:US
Practice Address - Phone:614-688-9220
Practice Address - Fax:614-688-9177
Is Sole Proprietor?:No
Enumeration Date:2012-05-18
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02004854A208000000X, 207R00000X
MI5101019944208000000X
OH34013697207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0336853Medicaid