Provider Demographics
NPI:1417925975
Name:KIRBY, SHANNON LEE (OD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:LEE
Last Name:KIRBY
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 1:2490 STANTONSBURG RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-7210
Mailing Address - Country:US
Mailing Address - Phone:252-752-4844
Mailing Address - Fax:252-752-7131
Practice Address - Street 1:2490 STANTONSBURG RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-7210
Practice Address - Country:US
Practice Address - Phone:252-752-4844
Practice Address - Fax:252-752-7131
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1814152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89093E9Medicaid
189296OtherMEDCOST
189296OtherMEDCOST