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NPI Code Detail

MEDICARE: DR. EVAN SHANNON MD

MEDICARE: DR. EVAN SHANNON MD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207R00000XInternal Medicine PhysicianA174141CA

General Provider Information

NPI Number : 1811378177
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. EVAN SHANNON MD
Provider Business Mailing Address
First Line : 5767 W CENTURY BLVD STE 400
Second Line :
City : LOS ANGELES
State : CA
Zip : 90045-5631
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 2211 MICHIGAN AVE
Second Line :
City : SANTA MONICA
State : CA
Zip : 90404-3905
Country : US
Telephone Number : 424-259-8085
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/12/2015
Last Update Date : 12/28/2023

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