Provider Demographics
NPI:1124438759
Name:IRIZA, SHANNON ELISABETH (DO)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:ELISABETH
Last Name:IRIZA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-296-7320
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:2 MEDICAL PARK RD STE 501
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6839
Practice Address - Country:US
Practice Address - Phone:803-540-1000
Practice Address - Fax:803-540-1011
Is Sole Proprietor?:No
Enumeration Date:2014-05-05
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDO034666207R00000X
SC82202207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC822024Medicaid