Provider Demographics
NPI:1720282163
Name:ROUTHOUSKA, SHANNON BROWN (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:BROWN
Last Name:ROUTHOUSKA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:220 LINDEN OAKS STE 300
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14625-2839
Mailing Address - Country:US
Mailing Address - Phone:585-383-4420
Mailing Address - Fax:585-383-4515
Practice Address - Street 1:220 LINDEN OAKS STE 300
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14625-2839
Practice Address - Country:US
Practice Address - Phone:585-383-4420
Practice Address - Fax:585-383-4515
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY233098-01207N00000X
OH57.009255207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY233098OtherMEDICAL LICENSE
NY03135811Medicaid