Provider Demographics
NPI:1932360161
Name:SMALL, SHANNON FR (MD)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:FR
Last Name:SMALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:365 MONTAUK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-4700
Mailing Address - Country:US
Mailing Address - Phone:860-443-3147
Mailing Address - Fax:860-865-2395
Practice Address - Street 1:365 MONTAUK AVE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4700
Practice Address - Country:US
Practice Address - Phone:860-443-3147
Practice Address - Fax:860-865-2395
Is Sole Proprietor?:No
Enumeration Date:2008-06-20
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL0361436862086S0102X
VA01012490012086S0102X
CT796452086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care