Healthcare Provider Details

I. General information

NPI: 1780267625
Provider Name (Legal Business Name): STEPHEN SHANNON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2021
Last Update Date: 12/18/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

395200 W 2900 RD
OCHELATA OK
74051-2463
US

IV. Provider business mailing address

395200 W 2900 RD
OCHELATA OK
74051-2463
US

V. Phone/Fax

Practice location:
  • Phone: 918-535-6000
  • Fax: 918-535-2697
Mailing address:
  • Phone: 918-535-6000
  • Fax: 918-535-2697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number38177
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: