Provider Demographics
NPI:1114910536
Name:MAIN, CAROL ANN SHEKER (OD)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:ANN SHEKER
Last Name:MAIN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:A
Other - Last Name:SHEKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
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:571-223-6780
Practice Address - Street 1:1220 PARKWOOD DR
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54494-5488
Practice Address - Country:US
Practice Address - Phone:715-421-2111
Practice Address - Fax:715-421-2123
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009797152W00000X
OR3476AT152W00000X
MN3058152W00000X
WI3055-035152WP0200X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics