Provider Demographics
NPI:1871532465
Name:AMONETTE, SHANNON LEIGH (MD)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:LEIGH
Last Name:AMONETTE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:SHANNON
Other - Middle Name:LEIGH
Other - Last Name:FOWLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:816 W CANNON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3146
Mailing Address - Country:US
Mailing Address - Phone:817-321-0312
Mailing Address - Fax:817-317-7033
Practice Address - Street 1:815 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2224
Practice Address - Country:US
Practice Address - Phone:817-321-0312
Practice Address - Fax:817-317-7033
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM14682085R0202X, 2085B0100X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1768848-05Medicaid
TX176884801Medicaid
I06933Medicare UPIN
TX176884801Medicaid
TXTXB120534Medicare PIN