Healthcare Provider Details

I. General information

NPI: 1508245689
Provider Name (Legal Business Name): SHANNON CALDWELL CLEMONS GOODE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNON CALDWELL CLEMONS MD

II. Dates (important events)

Enumeration Date: 05/22/2015
Last Update Date: 10/08/2024
Certification Date: 12/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 S CLEARVIEW PKWY
JEFFERSON LA
70121-1011
US

IV. Provider business mailing address

1514 JEFFERSON HWY
NEW ORLEANS LA
70121-2429
US

V. Phone/Fax

Practice location:
  • Phone: 504-842-6089
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number323811
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number039.146919
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: