Provider Demographics
NPI:1427261288
Name:DESHAZO, SHANNON L (MD)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:L
Last Name:DESHAZO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:L
Other - Last Name:FONVILLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5236 W. UNIVERSITY DR.
Mailing Address - Street 2:3200
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75071-8120
Mailing Address - Country:US
Mailing Address - Phone:972-548-1717
Mailing Address - Fax:972-548-9190
Practice Address - Street 1:5236 W. UNIVERSITY DR.
Practice Address - Street 2:3200
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75071-8120
Practice Address - Country:US
Practice Address - Phone:972-548-1717
Practice Address - Fax:972-548-9190
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE24244207Q00000X
TXN2469207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX614226Medicare PIN