Provider Demographics
NPI:1215059506
Name:DAVIS, SHANNON MICHELLE (DO)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:MICHELLE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:3820 NORTHDALE BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624-1893
Mailing Address - Country:US
Mailing Address - Phone:813-280-0705
Mailing Address - Fax:813-434-2023
Practice Address - Street 1:15303 S 94TH AVE STE 110
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-3825
Practice Address - Country:US
Practice Address - Phone:800-991-6117
Practice Address - Fax:888-812-8191
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2025-02-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036164424202K00000X, 208600000X
OH34.015496208600000X
KY05142208600000X
IN02003690A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No202K00000XAllopathic & Osteopathic PhysiciansPhlebology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0470386Medicaid
IN200992420Medicaid
KY7100787770Medicaid
INM400020983Medicare PIN