Provider Demographics
NPI:1528072089
Name:SHANAHAN, TIMOTHY J (DO)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:J
Last Name:SHANAHAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:522 IDLEWILD AVE
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:MD
Mailing Address - Zip Code:21601-3824
Mailing Address - Country:US
Mailing Address - Phone:410-822-5571
Mailing Address - Fax:410-822-3859
Practice Address - Street 1:522 IDLEWILD AVE
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:MD
Practice Address - Zip Code:21601-3824
Practice Address - Country:US
Practice Address - Phone:410-822-5571
Practice Address - Fax:410-822-3859
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH0064036174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDH0064036OtherSTATE MEDICAL LICENSE