Provider Demographics
NPI:1245321231
Name:SVENSEN, ROBERT SHANE (OD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:SHANE
Last Name:SVENSEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 E 10TH ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:ANNISTON
Mailing Address - State:AL
Mailing Address - Zip Code:36207-4787
Mailing Address - Country:US
Mailing Address - Phone:256-236-7516
Mailing Address - Fax:
Practice Address - Street 1:425 E 10TH ST
Practice Address - Street 2:SUITE C
Practice Address - City:ANNISTON
Practice Address - State:AL
Practice Address - Zip Code:36207-4787
Practice Address - Country:US
Practice Address - Phone:256-236-7516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001147152W00000X
ALS-646-TA-124152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000058010Medicaid
AL000058426Medicaid
AL000058010Medicaid
ALT69086Medicare UPIN
AL000058426Medicaid
AL0573680001Medicare NSC