Provider Demographics
NPI:1225171739
Name:SHANNON, EDWARD HOGAN JR (OD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:HOGAN
Last Name:SHANNON
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:422 GREEN STREET PL
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3318
Mailing Address - Country:US
Mailing Address - Phone:770-535-1467
Mailing Address - Fax:770-535-0763
Practice Address - Street 1:422 GREEN STREET PL
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3318
Practice Address - Country:US
Practice Address - Phone:770-535-1467
Practice Address - Fax:770-535-0763
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT000834152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA41ZCDTDMedicare PIN
41ZCDTDMedicare ID - Type Unspecified
GAT87012Medicare UPIN