Provider Demographics
NPI:1881647147
Name:KOONCE, MASHERRILL F (OD)
Entity Type:Individual
Prefix:DR
First Name:MASHERRILL
Middle Name:F
Last Name:KOONCE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9425 SOUTH BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28273-6900
Mailing Address - Country:US
Mailing Address - Phone:704-341-7676
Mailing Address - Fax:704-370-9751
Practice Address - Street 1:9425 SOUTH BLVD STE A
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273-6900
Practice Address - Country:US
Practice Address - Phone:704-341-7676
Practice Address - Fax:704-370-9751
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1393152W00000X
SC1000152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890920GMedicaid
NC890920GMedicaid