Basic Information
| Provider Information | |||||||||
| NPI: | 1407945819 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SUH | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | SUMI | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SUH | ||||||||
| OtherFirstName: | SHANNON | ||||||||
| OtherMiddleName: | SUMI | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | O.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1950 OLD GALLOWS RD | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221823990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038478899 | ||||||||
| FaxNumber: | 9727318635 | ||||||||
| Practice Location | |||||||||
| Address1: | 44727 BRIMFIELD DR | ||||||||
| Address2: | |||||||||
| City: | ASHBURN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201475920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5713854600 | ||||||||
| FaxNumber: | 5713854605 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 03/28/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 5808T | TX | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 5808T | VA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 0018FF | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | 12969 | 01 | TX | SPECTERA | OTHER | 919792 | 01 | TX | BLOCKVISON | OTHER | 48962 | 01 | TX | DAVIS VISION | OTHER |