Provider Demographics
NPI:1386899292
Name:TWIDDY, SHANNON KEITH (MD)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:KEITH
Last Name:TWIDDY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2002 S 11TH ST
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-4074
Mailing Address - Country:US
Mailing Address - Phone:269-687-0200
Mailing Address - Fax:269-471-7741
Practice Address - Street 1:2002 S 11TH ST
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-4074
Practice Address - Country:US
Practice Address - Phone:269-687-0200
Practice Address - Fax:269-471-7741
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-19
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9601201207Q00000X
MI4301093962207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine