Provider Demographics
NPI:1649262510
Name:SHANAHAN, WILLIAM J (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:J
Last Name:SHANAHAN
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 1:4511 N. DAVIS HWY SUITE C
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-2770
Mailing Address - Country:US
Mailing Address - Phone:850-484-8448
Mailing Address - Fax:850-479-3258
Practice Address - Street 1:4511 N. DAVIS HWY SUITE C
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2770
Practice Address - Country:US
Practice Address - Phone:850-484-8448
Practice Address - Fax:850-479-3258
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-17
Last Update Date:2015-06-23
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
FLME0032249174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL061290100Medicaid
FL010028302OtherRRB PTAN
FL010028302OtherRRB PTAN
FL061290100Medicaid
FL17563Medicare PIN