Healthcare Provider Details

I. General information

NPI: 1376803577
Provider Name (Legal Business Name): SHANNON DEAN M.D., PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2012
Last Update Date: 09/26/2024
Certification Date: 09/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 N CAROLINE ST FL 5
BALTIMORE MD
21287-0006
US

IV. Provider business mailing address

6201 GREENLEIGH AVE FL 2
MIDDLE RIVER MD
21220-2004
US

V. Phone/Fax

Practice location:
  • Phone: 410-955-4259
  • Fax:
Mailing address:
  • Phone: 410-933-2719
  • Fax: 585-424-7289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberP27654
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number289101
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License NumberP27654
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: