Provider Demographics
NPI:1669560603
Name:COLT, SHANNON JANE (MD)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:JANE
Last Name:COLT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SHANNON
Other - Middle Name:JANE
Other - Last Name:COLT-CONNAWAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:99 E STATE ST
Mailing Address - Street 2:PO BOX 1250
Mailing Address - City:GLOVERSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12078-1203
Mailing Address - Country:US
Mailing Address - Phone:518-775-4205
Mailing Address - Fax:518-775-4225
Practice Address - Street 1:110 DECKER DRIVE, SUITE 100
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:NY
Practice Address - Zip Code:12095-2316
Practice Address - Country:US
Practice Address - Phone:518-762-6731
Practice Address - Fax:518-762-7135
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY211113208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY411485OtherMVP HEALTHPLAN
NY01859278Medicaid
NY000927742002OtherBSH NE NY
NY411485OtherMVP HEALTHPLAN