Provider Demographics
NPI:1306852355
Name:WEBSTER, ROBERT SHANNON (OD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:SHANNON
Last Name:WEBSTER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 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 1:171 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-9027
Practice Address - Country:US
Practice Address - Phone:407-365-7475
Practice Address - Fax:407-365-6919
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2020-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3671152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL621187900Medicaid
FL621187900Medicaid
FLU2544ZMedicare PIN