Provider Demographics
NPI:1447886601
Name:SHOLLY, ALLISON ELIZABETH (OD)
Entity type:Individual
Prefix:
First Name:ALLISON
Middle Name:ELIZABETH
Last Name:SHOLLY
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 1:408 E JEANETTE LN
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-6017
Mailing Address - Country:US
Mailing Address - Phone:562-309-1080
Mailing Address - Fax:
Practice Address - Street 1:427 E 17TH ST STE C
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-3201
Practice Address - Country:US
Practice Address - Phone:949-642-2929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-19
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34740TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist