Provider Demographics
NPI:1952609091
Name:MARTIN, SHANNON ROEHL (DO)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:ROEHL
Last Name:MARTIN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 E MAIN ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-5382
Mailing Address - Country:US
Mailing Address - Phone:989-794-3200
Mailing Address - Fax:
Practice Address - Street 1:715 E MAIN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-5382
Practice Address - Country:US
Practice Address - Phone:989-794-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-13
Last Update Date:2015-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101019543207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program