Provider Demographics
NPI:1649375148
Name:SHANNON, JEFFREY STEVENS (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:STEVENS
Last Name:SHANNON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2027 VILLAGE LN
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SOLVANG
Mailing Address - State:CA
Mailing Address - Zip Code:93463-2283
Mailing Address - Country:US
Mailing Address - Phone:805-688-3440
Mailing Address - Fax:805-686-5694
Practice Address - Street 1:2027 VILLAGE LN
Practice Address - Street 2:SUITE 102
Practice Address - City:SOLVANG
Practice Address - State:CA
Practice Address - Zip Code:93463-2283
Practice Address - Country:US
Practice Address - Phone:805-688-3440
Practice Address - Fax:805-686-5694
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA36291208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE50877Medicare UPIN