Provider Demographics
NPI:1992876239
Name:ROESCH, SHANNON (DPM PC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:ROESCH
Suffix:
Gender:F
Credentials:DPM PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:242 JERICHO TPKE
Mailing Address - Street 2:
Mailing Address - City:FLORAL PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11001-2147
Mailing Address - Country:US
Mailing Address - Phone:516-488-6290
Mailing Address - Fax:516-488-3172
Practice Address - Street 1:242 JERICHO TPKE
Practice Address - Street 2:
Practice Address - City:FLORAL PARK
Practice Address - State:NY
Practice Address - Zip Code:11001-2147
Practice Address - Country:US
Practice Address - Phone:516-488-6290
Practice Address - Fax:516-488-3172
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005991213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00599165NYOther1199
NY6C1150OtherHEALTHNET
NY0151722OtherGHI
NY1779083OtherCIGNA
7444873OtherAETNA
NYP3722100OtherOXFORD
NYN005991OtherHIP
NYPL2751OtherBLUE CROSS BLUE SHIELD
NY1779083OtherCIGNA
NYPL2751OtherBLUE CROSS BLUE SHIELD
NYV03141Medicare UPIN
NY07906GMedicare PIN