Provider Demographics
NPI:1023633179
Name:ANDERSON, SHELBY ALYSE (OD)
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:ALYSE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:SHELBY
Other - Middle Name:ALYSE
Other - Last Name:ZAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
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:571-223-6780
Practice Address - Street 1:5560 W LOVERS LN STE 240
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75209-4287
Practice Address - Country:US
Practice Address - Phone:469-775-9700
Practice Address - Fax:806-791-4077
Is Sole Proprietor?:No
Enumeration Date:2020-06-15
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10025152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist