Healthcare Provider Details

I. General information

NPI: 1417164880
Provider Name (Legal Business Name): SHANNON L KAUFFMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 01/09/2024
Certification Date: 01/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WYOMING ST
DAYTON OH
45409-2722
US

IV. Provider business mailing address

PO BOX 750243
DAYTON OH
45475-0243
US

V. Phone/Fax

Practice location:
  • Phone: 937-208-5642
  • Fax:
Mailing address:
  • Phone: 937-709-5051
  • Fax: 937-709-5050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number01061639A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number35.093235
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number35.093235
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: