Provider Demographics
NPI:1528077823
Name:BURKE, SHANNON DOAK (DC)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:DOAK
Last Name:BURKE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 277
Mailing Address - Street 2:
Mailing Address - City:VIDOR
Mailing Address - State:TX
Mailing Address - Zip Code:77670-0277
Mailing Address - Country:US
Mailing Address - Phone:409-769-5115
Mailing Address - Fax:409-769-5215
Practice Address - Street 1:360 S MAIN ST
Practice Address - Street 2:
Practice Address - City:VIDOR
Practice Address - State:TX
Practice Address - Zip Code:77662-5752
Practice Address - Country:US
Practice Address - Phone:409-769-5115
Practice Address - Fax:409-769-5215
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5849111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX603506Medicare ID - Type Unspecified
TXU25362Medicare UPIN