Provider Demographics
NPI:1972056703
Name:SHAH, DHARA SHAILESH (OD)
Entity Type:Individual
Prefix:MS
First Name:DHARA
Middle Name:SHAILESH
Last Name:SHAH
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 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:866-795-4020
Practice Address - Street 1:1412 N AUGUSTA ST
Practice Address - Street 2:
Practice Address - City:STAUNTON
Practice Address - State:VA
Practice Address - Zip Code:24401-2401
Practice Address - Country:US
Practice Address - Phone:540-885-0006
Practice Address - Fax:540-885-5276
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-28
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA2543152W00000X
VA0618002645152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist