Healthcare Provider Details

I. General information

NPI: 1700106853
Provider Name (Legal Business Name): SHANNON J POTTER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2010
Last Update Date: 09/22/2025
Certification Date: 09/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3466 MCKELVEY RD
BRIDGETON MO
63044-2533
US

IV. Provider business mailing address

660 MASON RIDGE CENTER DR STE 300
SAINT LOUIS MO
63141-8512
US

V. Phone/Fax

Practice location:
  • Phone: 314-463-6950
  • Fax:
Mailing address:
  • Phone: 314-448-3791
  • Fax: 636-996-7658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2010017998
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: