Healthcare Provider Details

I. General information

NPI: 1265449441
Provider Name (Legal Business Name): MARGARET M SHANNON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 08/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 VICTORIA ST SUITE 1H
COSTA MESA CA
92627-1906
US

IV. Provider business mailing address

275 VICTORIA ST SUITE 1H
COSTA MESA CA
92627-1906
US

V. Phone/Fax

Practice location:
  • Phone: 949-646-2311
  • Fax: 949-646-1064
Mailing address:
  • Phone: 949-646-2311
  • Fax: 949-646-1064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberG42251
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: