Provider Demographics
NPI:1457313835
Name:BURGESS, SHANNON M (OD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:M
Last Name:BURGESS
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 1:1260 VALLEY FORGE RD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:PHOENIXVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19460-2691
Mailing Address - Country:US
Mailing Address - Phone:610-917-0700
Mailing Address - Fax:610-917-0708
Practice Address - Street 1:1260 VALLEY FORGE RD
Practice Address - Street 2:SUITE 108
Practice Address - City:PHOENIXVILLE
Practice Address - State:PA
Practice Address - Zip Code:19460-2691
Practice Address - Country:US
Practice Address - Phone:610-917-0700
Practice Address - Fax:610-917-0708
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-03
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000127152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1321149OtherHIGHMARK BLUE SHIELD
PA410047758OtherRAILROAD MEDICARE
PA0019559700001Medicaid
PA2669841OtherAETNA
PA50004981OtherCAPITAL BLUE CROSS
PA1321149OtherHIGHMARK BLUE SHIELD
PAU85232Medicare UPIN