Provider Demographics
NPI:1720280175
Name:FARMAKIS, SHANNON GRACE (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:GRACE
Last Name:FARMAKIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SHANNON
Other - Middle Name:GRACE
Other - Last Name:LEHNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:11475 OLDE CABIN RD STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7129
Mailing Address - Country:US
Mailing Address - Phone:314-991-8200
Mailing Address - Fax:314-991-8206
Practice Address - Street 1:615 S NEW BALLAS RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8221
Practice Address - Country:US
Practice Address - Phone:314-251-6031
Practice Address - Fax:314-251-6343
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2022-11-17
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2008-02-28
Provider Licenses
StateLicense IDTaxonomies
IDM-147822085P0229X, 2085R0202X
WAMD609620822085P0229X
KS04443252085R0202X
MO2008134562085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1720280175Medicaid
WA2140822Medicaid