Provider Demographics
NPI:1710114178
Name:KOEHLER, SHANNON MICHELLE (MD, PHD)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MICHELLE
Last Name:KOEHLER
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:MICHELLE
Other - Last Name:GIFFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3533 S ALAMEDA ST
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78411-1721
Mailing Address - Country:US
Mailing Address - Phone:361-694-4700
Mailing Address - Fax:361-808-2156
Practice Address - Street 1:3533 S ALAMEDA ST
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-1721
Practice Address - Country:US
Practice Address - Phone:361-694-4700
Practice Address - Fax:361-808-2156
Is Sole Proprietor?:No
Enumeration Date:2009-06-12
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS35432086S0120X
WI623852086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4040651Medicaid
WIK400143681Medicare PIN