Healthcare Provider Details

I. General information

NPI: 1477748648
Provider Name (Legal Business Name): SHANNON L GOLDSMITH D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2007
Last Update Date: 07/09/2020
Certification Date: 07/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

822 MAIN ST
ELLISVILLE MS
39437-2425
US

IV. Provider business mailing address

415 S 28TH AVE
HATTIESBURG MS
39401-7246
US

V. Phone/Fax

Practice location:
  • Phone: 601-477-2014
  • Fax: 601-477-9942
Mailing address:
  • Phone: 601-477-2014
  • Fax: 601-579-5240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34009767
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number24285
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: