Basic Information
| Provider Information | |||||||||
| NPI: | 1407162852 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOU | ||||||||
| FirstName: | SHANAR | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MOHAMMAD LOU | ||||||||
| OtherFirstName: | SHANAR | ||||||||
| OtherMiddleName: | HAJI SHAH | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7100 SIX FORKS RD | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276156156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198470187 | ||||||||
| FaxNumber: | 9196762231 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 WIDEWATERS PKWY | ||||||||
| Address2: | |||||||||
| City: | KNIGHTDALE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275456102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198612020 | ||||||||
| FaxNumber: | 9192770854 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2010 | ||||||||
| LastUpdateDate: | 10/15/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2205 | NC | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 5915885 | 05 | NC | MEDICAID | P01211057 | 01 | RAILROAD MEDICARE | OTHER | 0932U | 01 | NC | NORTH CAROLINA BCBS | OTHER |