Provider Demographics
NPI:1093260903
Name:DR. SHANNON JOSEPH O.D., LLC
Entity Type:Organization
Organization Name:DR. SHANNON JOSEPH O.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF OPTOMETRY
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:JOSEPH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:954-895-2530
Mailing Address - Street 1:304 INDIAN TRCE
Mailing Address - Street 2:#718
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33326-2996
Mailing Address - Country:US
Mailing Address - Phone:954-895-2530
Mailing Address - Fax:
Practice Address - Street 1:12801 W SUNRISE BLVD
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33323-4020
Practice Address - Country:US
Practice Address - Phone:954-895-2530
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-20
Last Update Date:2016-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC5208152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty