Provider Demographics
NPI:1326077157
Name:SHUSTOCK, PATRICIA ANNE (OD)
Entity Type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:ANNE
Last Name:SHUSTOCK
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 1:614 17TH ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20006-4802
Mailing Address - Country:US
Mailing Address - Phone:202-298-6878
Mailing Address - Fax:202-347-7180
Practice Address - Street 1:614 17TH ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20006-4802
Practice Address - Country:US
Practice Address - Phone:202-298-6878
Practice Address - Fax:202-347-7180
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCOP564152W00000X
MDTA0830152W00000X
VA0601-001171152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC157504Medicare ID - Type Unspecified
DC10090Medicare UPIN