Provider Demographics
NPI:1396060224
Name:JOSEPH, SHANNON SHAN (MD)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:SHAN
Last Name:JOSEPH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:SHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3940 JOHN R RD
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-5688
Mailing Address - Country:US
Mailing Address - Phone:947-217-3223
Mailing Address - Fax:
Practice Address - Street 1:3940 JOHN R RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-5688
Practice Address - Country:US
Practice Address - Phone:248-455-4169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-04
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD81623207W00000X
MI4301104534207W00000X, 207WX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive Surgery
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology