Provider Demographics
NPI:1720024821
Name:SHOOTER, JR., EUGENE A (PHD)
Entity Type:Individual
Prefix:DR
First Name:EUGENE
Middle Name:A
Last Name:SHOOTER, JR.
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:GENE
Other - Middle Name:
Other - Last Name:SHOOTER, JR.
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:5276 DAWES AVE
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22311-1404
Mailing Address - Country:US
Mailing Address - Phone:703-379-7350
Mailing Address - Fax:703-379-7352
Practice Address - Street 1:5276 DAWES AVE
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22311-1404
Practice Address - Country:US
Practice Address - Phone:703-379-7350
Practice Address - Fax:703-379-7352
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA00810002612103TC0700X
DCPSY1878103TC0700X
HIPSY518103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA110936OtherPCI APS
VA2787110OtherPCI AETNA
VA142975OtherT-MED BC/BS VA
VA158367OtherPCI TRICARE
VA158367OtherPCI VALUE OPTIONS
VA48900016OtherCAREFIRST BC/BS
VA453769OtherPCI ANTHEM
DCG3960017OtherBCBS DC
VA2122539OtherMAMSI
VA228758OtherPCI KAISER PERMANENTE
VA9123953OtherPHCS
VA142975OtherANTHEM HEALTHKEEPERS
VA228758OtherPCI KAISER PERMANENTE
VA2122539OtherMAMSI