Provider Demographics
NPI:1043385511
Name:CHANDLER, SHANNON R (OD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:R
Last Name:CHANDLER
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 1:3962 BLUE DIAMOND RD
Mailing Address - Street 2:STE 105
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89139-7795
Mailing Address - Country:US
Mailing Address - Phone:702-791-6860
Mailing Address - Fax:702-791-7028
Practice Address - Street 1:3962 BLUE DIAMOND RD STE 105
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89139-7795
Practice Address - Country:US
Practice Address - Phone:702-791-6860
Practice Address - Fax:702-791-7028
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV455152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV38720Medicare ID - Type Unspecified
NVU99200Medicare UPIN