Provider Demographics
NPI:1487191243
Name:MELISSA A GIBSON SHOTTS OPTOMETRIST
Entity Type:Organization
Organization Name:MELISSA A GIBSON SHOTTS OPTOMETRIST
Other - Org Name:MELISSA SHOTTS
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:A
Authorized Official - Last Name:SHOTTS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:205-412-5509
Mailing Address - Street 1:PO BOX 1807
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:AL
Mailing Address - Zip Code:35570-1807
Mailing Address - Country:US
Mailing Address - Phone:205-921-7426
Mailing Address - Fax:205-921-7589
Practice Address - Street 1:1925 MILITARY ST S
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:AL
Practice Address - Zip Code:35570-6674
Practice Address - Country:US
Practice Address - Phone:205-921-7426
Practice Address - Fax:205-921-7589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-31
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-C36-TA-873152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL199936Medicaid