Healthcare Provider Details

I. General information

NPI: 1598729444
Provider Name (Legal Business Name): SHANNON MARIE MCCOLE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2006
Last Update Date: 01/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 GRESHAM DR
NORFOLK VA
23507-1904
US

IV. Provider business mailing address

PO BOX 936
NORFOLK VA
23501-0936
US

V. Phone/Fax

Practice location:
  • Phone: 757-461-0050
  • Fax: 757-461-4538
Mailing address:
  • Phone: 757-627-4512
  • Fax: 757-461-4538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number0101056000
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: