Basic Information
Provider Information | |||||||||
NPI: | 1649363946 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MUDD | ||||||||
FirstName: | SHAWN | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | OD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1440 RIVERSIDE AVE | ||||||||
Address2: |   | ||||||||
City: | BALTIMORE | ||||||||
State: | MD | ||||||||
PostalCode: | 21230 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6464839295 | ||||||||
FaxNumber: | 4105444408 | ||||||||
Practice Location | |||||||||
Address1: | 580 E RITCHIE HWY | ||||||||
Address2: |   | ||||||||
City: | SEVERNA PARK | ||||||||
State: | MD | ||||||||
PostalCode: | 21146 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4105447417 | ||||||||
FaxNumber: | 4105444408 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/02/2006 | ||||||||
LastUpdateDate: | 01/28/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | TA2008 | MD | Y |   | Eye and Vision Services Providers | Optometrist |   | 152WC0802X | TA2008 | MD | N |   | Eye and Vision Services Providers | Optometrist | Corneal and Contact Management |
No ID Information.