Provider Demographics
NPI:1437125093
Name:LOE, SHANAN (MD)
Entity type:Individual
Prefix:DR
First Name:SHANAN
Middle Name:
Last Name:LOE
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 1:4203 BELFORT ROAD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-1463
Mailing Address - Country:US
Mailing Address - Phone:904-296-5688
Mailing Address - Fax:904-296-5699
Practice Address - Street 1:4203 BELFORT ROAD
Practice Address - Street 2:SUITE 204
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-1463
Practice Address - Country:US
Practice Address - Phone:904-296-5688
Practice Address - Fax:904-296-5699
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME93888207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA788979252AMedicaid
FL2732653-00Medicaid
GA788979252AMedicaid
FL29331ZMedicare PIN