Provider Demographics
NPI:1932188604
Name:SHOUP, CYNTHIA E (OD)
Entity Type:Individual
Prefix:DR
First Name:CYNTHIA
Middle Name:E
Last Name:SHOUP
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 1:119 1ST AVE W
Mailing Address - Street 2:
Mailing Address - City:OSKALOOSA
Mailing Address - State:IA
Mailing Address - Zip Code:52577-3243
Mailing Address - Country:US
Mailing Address - Phone:641-673-7708
Mailing Address - Fax:641-673-0979
Practice Address - Street 1:119 1ST AVE W
Practice Address - Street 2:
Practice Address - City:OSKALOOSA
Practice Address - State:IA
Practice Address - Zip Code:52577-3243
Practice Address - Country:US
Practice Address - Phone:641-673-7708
Practice Address - Fax:641-673-0979
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1757152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0187526Medicaid
IAU21002Medicare UPIN
IA18752Medicare ID - Type Unspecified