Provider Demographics
NPI:1285797324
Name:STANEK, SHANNON K (OD)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:K
Last Name:STANEK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:947 S CEDAR ST
Mailing Address - Street 2:APT #7
Mailing Address - City:MASON
Mailing Address - State:MI
Mailing Address - Zip Code:48854-2069
Mailing Address - Country:US
Mailing Address - Phone:517-896-0115
Mailing Address - Fax:
Practice Address - Street 1:1736 W MICHIGAN AVE
Practice Address - Street 2:WESTWOOD MALL
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-4005
Practice Address - Country:US
Practice Address - Phone:517-789-7131
Practice Address - Fax:517-789-7111
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4901004252152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI162233Medicare UPIN