Provider Demographics
NPI:1528001278
Name:SHOTER, ROSS JAY (OD)
Entity Type:Individual
Prefix:
First Name:ROSS
Middle Name:JAY
Last Name:SHOTER
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 1:18111 TOWN CENTER DR
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:MD
Mailing Address - Zip Code:20832-1479
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1950 OLD GALLOWS RD
Practice Address - Street 2:#100
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-3990
Practice Address - Country:US
Practice Address - Phone:703-847-8899
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA1631152W00000X
VA0618001113152W00000X
DCOP823152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDU92687Medicare UPIN