Provider Demographics
NPI:1114478468
Name:SHIPMAN, ELIZABETH (OD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:SHIPMAN
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 1:3700 SAN PABLO AVE
Mailing Address - Street 2:UNIT 5
Mailing Address - City:HERCULES
Mailing Address - State:CA
Mailing Address - Zip Code:94547-3968
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3700 SAN PABLO AVE
Practice Address - Street 2:UNIT 5
Practice Address - City:HERCULES
Practice Address - State:CA
Practice Address - Zip Code:94547-3968
Practice Address - Country:US
Practice Address - Phone:510-741-9900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-21
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12188T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU94746Medicare UPIN