Basic Information
Provider Information | |||||||||
NPI: | 1235198342 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | OATES | ||||||||
FirstName: | SHANNON | ||||||||
MiddleName: | K | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1200 W WHITE RIVER BLVD | ||||||||
Address2: |   | ||||||||
City: | MUNCIE | ||||||||
State: | IN | ||||||||
PostalCode: | 473034988 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8776685621 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2600 FERRY ST | ||||||||
Address2: |   | ||||||||
City: | LAFAYETTE | ||||||||
State: | IN | ||||||||
PostalCode: | 479043055 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7654488000 | ||||||||
FaxNumber: | 7654488858 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/20/2006 | ||||||||
LastUpdateDate: | 02/03/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/03/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | 01037819A | IN | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
ID | Type | State | Issuer | Description | 9397348 | 01 | IN | PHCS PID NUMBER | OTHER | 10825685 | 01 | IN | CAQH NUMBER | OTHER | 100095490 | 05 | IN |   | MEDICAID | 000000180974 | 01 | IN | ANTHEM PROVIDER NUMBER | OTHER | OA17622011 | 05 | IN |   | MEDICAID |