Provider Demographics
NPI:1548491293
Name:ZOLLINGER, SHANNON MARIE (OD)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:ZOLLINGER
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:PO BOX 1290
Mailing Address - Street 2:
Mailing Address - City:FOREST
Mailing Address - State:VA
Mailing Address - Zip Code:24551-1290
Mailing Address - Country:US
Mailing Address - Phone:434-385-5600
Mailing Address - Fax:434-455-7172
Practice Address - Street 1:4244 VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24078
Practice Address - Country:US
Practice Address - Phone:434-385-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-29
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5912152W00000X
CT002827152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1548491293Medicaid
CTC00681OtherPTAN