Healthcare Provider Details

I. General information

NPI: 1609158260
Provider Name (Legal Business Name): DELPHINE K. SHANNON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DELPHINE K. VANDERPOOL M.D.

II. Dates (important events)

Enumeration Date: 09/09/2011
Last Update Date: 09/06/2023
Certification Date: 09/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15429 ONEAL RD
GULFPORT MS
39503-2731
US

IV. Provider business mailing address

15429 ONEAL RD
GULFPORT MS
39503-2731
US

V. Phone/Fax

Practice location:
  • Phone: 228-206-0542
  • Fax: 228-206-0550
Mailing address:
  • Phone: 228-206-0542
  • Fax: 228-206-0550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code132700000X
TaxonomyDietary Manager
License Number18668
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number18668
License Number StateMS
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number18668
License Number StateMS
# 4
Primary TaxonomyN
Taxonomy Code207QB0002X
TaxonomyObesity Medicine (Family Medicine) Physician
License Number18668
License Number StateMS
# 5
Primary TaxonomyN
Taxonomy Code207RB0002X
TaxonomyObesity Medicine (Internal Medicine) Physician
License Number18668
License Number StateMS
# 6
Primary TaxonomyN
Taxonomy Code2088F0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Urology) Physician
License Number18668
License Number StateMS
# 7
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number18668
License Number StateMS
# 8
Primary TaxonomyN
Taxonomy Code202D00000X
TaxonomyIntegrative Medicine Physician
License Number18668
License Number StateMS
# 9
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number18668
License Number StateMS
# 10
Primary TaxonomyN
Taxonomy Code2080B0002X
TaxonomyPediatric Obesity Medicine Physician
License Number18668
License Number StateMS
# 11
Primary TaxonomyN
Taxonomy Code2083B0002X
TaxonomyObesity Medicine (Preventive Medicine) Physician
License Number18668
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: