Healthcare Provider Details

I. General information

NPI: 1144204405
Provider Name (Legal Business Name): SHANNON CLAYE WEBB M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 11/20/2024
Certification Date: 11/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

IVY CLINIC - BUILDING 7503 1650 COCHRANE CIRCLE
FORT CARSON CO
80913
US

IV. Provider business mailing address

5818 VILLA LORENZO DR
COLORADO SPRINGS CO
80919-5415
US

V. Phone/Fax

Practice location:
  • Phone: 719-524-4068
  • Fax: 719-526-7132
Mailing address:
  • Phone: 864-494-2134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD0091535
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDR0071691
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number22749
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: