Healthcare Provider Details

I. General information

NPI: 1447091657
Provider Name (Legal Business Name): SHAWNA MOINIPOUR O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DR. SHAWNA MOINIPOUR

II. Dates (important events)

Enumeration Date: 06/03/2024
Last Update Date: 06/03/2024
Certification Date: 06/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 HAMPTON POINT DR STE 3
ST AUGUSTINE FL
32092-3058
US

IV. Provider business mailing address

161 HAMPTON POINT DR STE 3
ST AUGUSTINE FL
32092-3058
US

V. Phone/Fax

Practice location:
  • Phone: 904-287-9137
  • Fax:
Mailing address:
  • Phone: 904-287-9057
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number6454
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: