Provider Demographics
NPI:1649363946
Name:MUDD, SHAWN M (OD)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:M
Last Name:MUDD
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 1:1440 RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21230
Mailing Address - Country:US
Mailing Address - Phone:646-483-9295
Mailing Address - Fax:410-544-4408
Practice Address - Street 1:580 E RITCHIE HWY
Practice Address - Street 2:
Practice Address - City:SEVERNA PARK
Practice Address - State:MD
Practice Address - Zip Code:21146
Practice Address - Country:US
Practice Address - Phone:410-544-7417
Practice Address - Fax:410-544-4408
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA2008152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management