Healthcare Provider Details

I. General information

NPI: 1689834640
Provider Name (Legal Business Name): SHANNON EILEEN O'MALLEY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2008
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 BROADHOLLOW RD STE 150
MELVILLE NY
11747-4909
US

IV. Provider business mailing address

175 BROADHOLLOW RD STE 150
MELVILLE NY
11747-4909
US

V. Phone/Fax

Practice location:
  • Phone: 631-386-4100
  • Fax:
Mailing address:
  • Phone: 631-386-4100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number260989
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: