Provider Demographics
NPI:1104023290
Name:BROWN, SHANNAN ELIZABETH (OD)
Entity Type:Individual
Prefix:
First Name:SHANNAN
Middle Name:ELIZABETH
Last Name:BROWN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:SHANNAN
Other - Middle Name:ELIZABETH
Other - Last Name:SZUBA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:230 E DAY RD STE 100
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-3408
Mailing Address - Country:US
Mailing Address - Phone:574-271-3939
Mailing Address - Fax:574-271-3941
Practice Address - Street 1:230 E DAY RD STE 100
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-3408
Practice Address - Country:US
Practice Address - Phone:574-271-3939
Practice Address - Fax:574-271-3941
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003466A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00991570OtherRR MEDICARE
IN18003466AOtherLICENSE
IN200864240Medicaid
IN4823160003Medicare NSC
IN4823160002Medicare NSC
INM400051429Medicare PIN
INP00991570OtherRR MEDICARE
IN4823160004Medicare NSC