Provider Demographics
NPI:1447091657
Name:MOINIPOUR, SHAWNA (OD)
Entity type:Individual
Prefix:
First Name:SHAWNA
Middle Name:
Last Name:MOINIPOUR
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:SHAWNA
Other - Middle Name:
Other - Last Name:MOINIPOUR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:161 HAMPTON POINT DR STE 3
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-3058
Mailing Address - Country:US
Mailing Address - Phone:904-287-9057
Mailing Address - Fax:
Practice Address - Street 1:161 HAMPTON POINT DR STE 3
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-3058
Practice Address - Country:US
Practice Address - Phone:904-287-9137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-03
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6454152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist