Provider Demographics
NPI:1821353566
Name:BLACKWOOD, SHANNON LEIGH BROWN (OD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:LEIGH BROWN
Last Name:BLACKWOOD
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 1:107 SUMMERGLEN DR
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28806-9524
Mailing Address - Country:US
Mailing Address - Phone:803-984-0671
Mailing Address - Fax:
Practice Address - Street 1:645 PATTON AVE
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28806-3834
Practice Address - Country:US
Practice Address - Phone:828-251-1290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-09
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1701152W00000X
NC2270152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist