Healthcare Provider Details

I. General information

NPI: 1265870455
Provider Name (Legal Business Name): NICOLE VO SHASTRI O.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2013
Last Update Date: 06/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3118 DONNELL DR
FORESTVILLE MD
20747-3203
US

IV. Provider business mailing address

3118 DONNELL DR
FORESTVILLE MD
20747-3203
US

V. Phone/Fax

Practice location:
  • Phone: 301-735-5600
  • Fax:
Mailing address:
  • Phone: 301-735-5600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTA2348
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: