Provider Demographics
NPI:1023209350
Name:DAVIDSON, SHANNON (OD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 W FIFTH ST
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43040
Mailing Address - Country:US
Mailing Address - Phone:937-644-8637
Mailing Address - Fax:937-644-8653
Practice Address - Street 1:1001 W FIFTH ST
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040
Practice Address - Country:US
Practice Address - Phone:937-644-8637
Practice Address - Fax:937-644-8653
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5704152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2824617Medicaid