1508196668 NPI number — GARRY C. SHOEMAKER, O.D., P.C.

Table of content: (NPI 1508196668)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508196668 NPI number — GARRY C. SHOEMAKER, O.D., P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GARRY C. SHOEMAKER, O.D., P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508196668
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/30/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1608 PLEASURE HOUSE RD
Provider Second Line Business Mailing Address:
SUITE 106
Provider Business Mailing Address City Name:
VIRGINIA BEACH
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23455-4046
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-460-9402
Provider Business Mailing Address Fax Number:
757-460-9462

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1608 PLEASURE HOUSE RD
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
VIRGINIA BEACH
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23455-4046
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-460-9402
Provider Business Practice Location Address Fax Number:
757-460-9462
Provider Enumeration Date:
01/12/2010

Additional Information

Authorized Official

Authorized Official Last Name:
DIAZ
Authorized Official First Name:
OSVALDO
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
757-460-9402

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  0618000704 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 009233849 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 33036 . This is a "OPTIMA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: DQ0280 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 394271 . This is a "ANTHEM BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 5464802 . This is a "AETNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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