Provider Demographics
NPI:1912984394
Name:SOVNDAL, SHANNON SMITH
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:SMITH
Last Name:SOVNDAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:S
Other - Last Name:SOVNDAL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:P.O. BOX 173894
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-3404
Mailing Address - Country:US
Mailing Address - Phone:303-306-7783
Mailing Address - Fax:303-306-7753
Practice Address - Street 1:1100 BALSAM AVE
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-3404
Practice Address - Country:US
Practice Address - Phone:303-440-2037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO41265207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO86032330Medicaid
COP00019485OtherRAILROAD MEDICARE
COP00019485OtherRAILROAD MEDICARE
CO498148Medicare PIN