1720024821 NPI number — DR. EUGENE A. SHOOTER, JR. PH.D.

Table of content: DR. EUGENE A. SHOOTER, JR. PH.D. (NPI 1720024821)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720024821 NPI number — DR. EUGENE A. SHOOTER, JR. PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHOOTER, JR.
Provider First Name:
EUGENE
Provider Middle Name:
A.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SHOOTER, JR.
Provider Other First Name:
GENE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PH.D.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1720024821
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/06/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5276 DAWES AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALEXANDRIA
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22311-1404
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-379-7350
Provider Business Mailing Address Fax Number:
703-379-7352

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5276 DAWES AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALEXANDRIA
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22311-1404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-379-7350
Provider Business Practice Location Address Fax Number:
703-379-7352
Provider Enumeration Date:
06/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  00810002612 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103TC0700X , with the licence number: PSY1878 , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X , with the licence number: PSY518 , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 110936 . This is a "PCI APS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 2787110 . This is a "PCI AETNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 142975 . This is a "T-MED BC/BS VA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 158367 . This is a "PCI TRICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 158367 . This is a "PCI VALUE OPTIONS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 48900016 . This is a "CAREFIRST BC/BS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 453769 . This is a "PCI ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: G3960017 . This is a "BCBS DC" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 2122539 . This is a "MAMSI" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 228758 . This is a "PCI KAISER PERMANENTE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 9123953 . This is a "PHCS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 142975 . This is a "ANTHEM HEALTHKEEPERS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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