Provider Demographics
NPI:1316957822
Name:GALLENTINE, SHANNON LEE (DPM)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:LEE
Last Name:GALLENTINE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 EUBANKS RD
Mailing Address - Street 2:
Mailing Address - City:MAYPEARL
Mailing Address - State:TX
Mailing Address - Zip Code:76064-1828
Mailing Address - Country:US
Mailing Address - Phone:469-383-9306
Mailing Address - Fax:972-435-2915
Practice Address - Street 1:150 EUBANKS RD
Practice Address - Street 2:
Practice Address - City:MAYPEARL
Practice Address - State:TX
Practice Address - Zip Code:76064-1828
Practice Address - Country:US
Practice Address - Phone:469-383-9306
Practice Address - Fax:972-435-2915
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2009-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1513213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX613786Medicare PIN