Provider Demographics
NPI:1902965965
Name:SMITH, CAROLYN SHANNON (MD)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:SHANNON
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 W INDIAN CREEK CT
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-2323
Mailing Address - Country:US
Mailing Address - Phone:414-540-6593
Mailing Address - Fax:
Practice Address - Street 1:545 N 15TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53233-2237
Practice Address - Country:US
Practice Address - Phone:414-288-7184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI38125207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIG74601Medicare UPIN