Healthcare Provider Details

I. General information

NPI: 1124231154
Provider Name (Legal Business Name): SHANNON CAMPBELL TROTTER D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNON MAUREEN CAMPBELL D.O.

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 09/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 W MCCREIGHT AVE SUITE 110
SPRINGFIELD OH
45504-1842
US

IV. Provider business mailing address

5400 FRANTZ RD STE 250
DUBLIN OH
43016-6102
US

V. Phone/Fax

Practice location:
  • Phone: 937-523-9880
  • Fax: 937-523-9899
Mailing address:
  • Phone: 937-523-9880
  • Fax: 937-523-9899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number34.009495
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34.013026
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: