Healthcare Provider Details

I. General information

NPI: 1578595922
Provider Name (Legal Business Name): GARRY CARLTON SHOEMAKER O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 02/12/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1608 PLEASURE HOUSE RD SUITE 106
VIRGINIA BEACH VA
23455-4046
US

IV. Provider business mailing address

1608 PLEASURE HOUSE RD SUITE 106
VIRGINIA BEACH VA
23455-4046
US

V. Phone/Fax

Practice location:
  • Phone: 757-460-9402
  • Fax: 757-460-9462
Mailing address:
  • Phone: 757-460-9402
  • Fax: 757-460-9462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618000704
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number0618000704
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: