Healthcare Provider Details

I. General information

NPI: 1114716131
Provider Name (Legal Business Name): SHANNON WATKINS OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2025
Last Update Date: 06/07/2026
Certification Date: 06/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2615 CAPITOL AVE
SACRAMENTO CA
95816-5904
US

IV. Provider business mailing address

4241 MADDIE CIR
STOCKTON CA
95209-3806
US

V. Phone/Fax

Practice location:
  • Phone: 916-447-2020
  • Fax:
Mailing address:
  • Phone: 209-470-5062
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number36259
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: