Provider Demographics
NPI:1205080553
Name:BROWN, SHANTHY SANDRASEKARAMUDALY (OD)
Entity type:Individual
Prefix:
First Name:SHANTHY
Middle Name:SANDRASEKARAMUDALY
Last Name:BROWN
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 1:615 S CONESTOGA ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19143-2514
Mailing Address - Country:US
Mailing Address - Phone:215-305-0611
Mailing Address - Fax:
Practice Address - Street 1:6633 GERMANTOWN AVE
Practice Address - Street 2:UNIT A
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19119-2253
Practice Address - Country:US
Practice Address - Phone:215-422-3636
Practice Address - Fax:215-422-3748
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-13
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG002168152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA168988Medicare PIN