Provider Demographics
NPI:1215907704
Name:SCHANTZ, SHANNON D (MD)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:D
Last Name:SCHANTZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 NE 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:PAYETTE
Mailing Address - State:ID
Mailing Address - Zip Code:83661-5420
Mailing Address - Country:US
Mailing Address - Phone:208-642-9376
Mailing Address - Fax:208-642-9598
Practice Address - Street 1:207 E 12TH ST
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617-3626
Practice Address - Country:US
Practice Address - Phone:208-365-1065
Practice Address - Fax:208-365-1065
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2025-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD26870207Q00000X
IDM6302207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000269700Medicaid
ID000010005294OtherREGENCE BLUE CHIELD
ID080167093OtherRR MEDICARE
ID40667OtherBLUE CROSS
ID000010005294OtherREGENCE BLUE CHIELD
ID080167093OtherRR MEDICARE
ID000269700Medicaid
IDE95064Medicare UPIN