Provider Demographics
NPI:1144374356
Name:SHANNON, BRIDGET ANN (OD)
Entity type:Individual
Prefix:DR
First Name:BRIDGET
Middle Name:ANN
Last Name:SHANNON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 S ALMA DR
Mailing Address - Street 2:200
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-3771
Mailing Address - Country:US
Mailing Address - Phone:972-747-1122
Mailing Address - Fax:214-383-0838
Practice Address - Street 1:203 S ALMA DR
Practice Address - Street 2:200
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-3771
Practice Address - Country:US
Practice Address - Phone:972-747-1122
Practice Address - Fax:214-383-0838
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5157TG152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXV05227Medicare UPIN
TX8F0348Medicare ID - Type Unspecified