Provider Demographics
NPI:1285723791
Name:SHANON, ROY M (MD)
Entity type:Individual
Prefix:DR
First Name:ROY
Middle Name:M
Last Name:SHANON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:616 BARDINI DR
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-5264
Mailing Address - Country:US
Mailing Address - Phone:516-316-0983
Mailing Address - Fax:631-423-1949
Practice Address - Street 1:616 BARDINI DR
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-5264
Practice Address - Country:US
Practice Address - Phone:516-316-0983
Practice Address - Fax:631-423-1949
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY175599207R00000X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1922517598OtherEMBLEM HEALTH GHI
NY1922517598OtherHEALTHFIRST
NY1922517598OtherUHC
NY1922517598OtherMULTIPLAN
1922517598OtherAETNA
NY1952517598OtherFIDELIS
NY1922517598OtherOXFORD HEALTH PLAN
NY1922517598OtherCIGNA
1952517598Other1199 NATIONAL BENEFITS FUND