Provider Demographics
NPI:1770719668
Name:BERRY, SHANNON GAMMILL (MD)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:GAMMILL
Last Name:BERRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:GAMMILL
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1635 MARVEL ST
Mailing Address - Street 2:
Mailing Address - City:COUSHATTA
Mailing Address - State:LA
Mailing Address - Zip Code:71019-9022
Mailing Address - Country:US
Mailing Address - Phone:318-932-2000
Mailing Address - Fax:
Practice Address - Street 1:1635 MARVEL ST
Practice Address - Street 2:
Practice Address - City:COUSHATTA
Practice Address - State:LA
Practice Address - Zip Code:71019-9022
Practice Address - Country:US
Practice Address - Phone:318-932-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-05
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP1727207Q00000X, 207Q00000X
LA208173207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2400894Medicaid
LAP01575286OtherRAILROAD MEDICARE PTAN
LA2400894Medicaid