Provider Demographics
NPI:1689630246
Name:MOORE, SHANNON JESSICA (OD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:JESSICA
Last Name:MOORE
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 1:528 WATERLOO RD
Mailing Address - Street 2:
Mailing Address - City:WARRENTON
Mailing Address - State:VA
Mailing Address - Zip Code:20186-3011
Mailing Address - Country:US
Mailing Address - Phone:571-276-0237
Mailing Address - Fax:540-347-9198
Practice Address - Street 1:528 WATERLOO RD
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:VA
Practice Address - Zip Code:20186-3011
Practice Address - Country:US
Practice Address - Phone:540-347-0555
Practice Address - Fax:540-347-9198
Is Sole Proprietor?:No
Enumeration Date:2006-04-24
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001510152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA11505363OtherUHC
VA2140911OtherMAMSI
VA187369OtherANTHEM BCBS
VA3991583OtherAETNA
VA3991583OtherAETNA
VAV06609Medicare UPIN