Healthcare Provider Details

I. General information

NPI: 1215249461
Provider Name (Legal Business Name): MINU SHAH O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2010
Last Update Date: 07/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 N SHENANDOAH AVE
FRONT ROYAL VA
22630-3531
US

IV. Provider business mailing address

520 COLSTON PL APT 302
WINCHESTER VA
22601-6620
US

V. Phone/Fax

Practice location:
  • Phone: 919-302-6336
  • Fax:
Mailing address:
  • Phone: 919-302-6336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618001959
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number0618001959
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number0618001959
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: