Provider Demographics
NPI:1205184488
Name:EVANS, SHANNON MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:MARIE
Last Name:EVANS
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 1:235 NW 207TH TER
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33029-3506
Mailing Address - Country:US
Mailing Address - Phone:302-670-4096
Mailing Address - Fax:
Practice Address - Street 1:1711 NE 163RD ST
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33162-4732
Practice Address - Country:US
Practice Address - Phone:302-670-4096
Practice Address - Fax:305-949-0703
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-21
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 4704152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014059500Medicaid