Provider Demographics
NPI:1649503558
Name:SHANKS, DAMON EDWIN (IDMT)
Entity type:Individual
Prefix:MR
First Name:DAMON
Middle Name:EDWIN
Last Name:SHANKS
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:5215 FONTAINE LN
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45502-9816
Mailing Address - Country:US
Mailing Address - Phone:937-525-2582
Mailing Address - Fax:937-327-2387
Practice Address - Street 1:5215 FONTAINE LN
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45502-9816
Practice Address - Country:US
Practice Address - Phone:937-525-2582
Practice Address - Fax:937-327-2387
Is Sole Proprietor?:No
Enumeration Date:2009-09-09
Last Update Date:2009-09-09
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians