Healthcare Provider Details

I. General information

NPI: 1689771933
Provider Name (Legal Business Name): SHANNON MICHELLE NOVOSAD VERMA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNON MICHELLE NOVOSAD

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 08/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5300 FAR HILLS AVENUE
DAYTON OH
45429-2347
US

IV. Provider business mailing address

10708 COUNTRY WALK CT.
CENTERVILLE OH
45458
US

V. Phone/Fax

Practice location:
  • Phone: 937-433-7536
  • Fax: 937-433-9612
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number35.090812
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: