Provider Demographics
NPI:1457314858
Name:SHANNON, TIMOTHY W (OD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:W
Last Name:SHANNON
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 1:1234 7TH ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90401-1614
Mailing Address - Country:US
Mailing Address - Phone:310-395-5778
Mailing Address - Fax:310-458-9754
Practice Address - Street 1:1234 7TH ST
Practice Address - Street 2:SUITE 2
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-1614
Practice Address - Country:US
Practice Address - Phone:310-395-5778
Practice Address - Fax:310-458-9754
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-08
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT6800TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT70141Medicare UPIN