Provider Demographics
NPI:1053300616
Name:SHIN, THERESA M (OD)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:M
Last Name:SHIN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:THERESA
Other - Middle Name:M
Other - Last Name:CHUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:866-795-4020
Practice Address - Street 1:6455 DOBBIN RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-5828
Practice Address - Country:US
Practice Address - Phone:443-542-5999
Practice Address - Fax:443-542-5175
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA1959152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist