Basic Information
Provider Information | |||||||||
NPI: | 1114910536 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MAIN | ||||||||
FirstName: | CAROL | ||||||||
MiddleName: | ANN SHEKER | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | OD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SHEKER | ||||||||
OtherFirstName: | CAROL | ||||||||
OtherMiddleName: | A | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | O.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1950 OLD GALLOWS RD STE 520 | ||||||||
Address2: |   | ||||||||
City: | VIENNA | ||||||||
State: | VA | ||||||||
PostalCode: | 221823970 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7038478899 | ||||||||
FaxNumber: | 5712236780 | ||||||||
Practice Location | |||||||||
Address1: | 1220 PARKWOOD DR | ||||||||
Address2: |   | ||||||||
City: | WISCONSIN RAPIDS | ||||||||
State: | WI | ||||||||
PostalCode: | 544945488 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7154212111 | ||||||||
FaxNumber: | 7154212123 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/31/2005 | ||||||||
LastUpdateDate: | 05/24/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/24/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 046009797 | IL | N |   | Eye and Vision Services Providers | Optometrist |   | 152W00000X | 3476AT | OR | N |   | Eye and Vision Services Providers | Optometrist |   | 152W00000X | 3058 | MN | N |   | Eye and Vision Services Providers | Optometrist |   | 152WP0200X | 3055-035 | WI | N |   | Eye and Vision Services Providers | Optometrist | Pediatrics | 152W00000X | 3055-035 | WI | Y |   | Eye and Vision Services Providers | Optometrist |   |
No ID Information.