Provider Demographics
NPI:1174648943
Name:ELLEN SHUHAM OD INC
Entity Type:Organization
Organization Name:ELLEN SHUHAM OD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR
Authorized Official - Prefix:
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHUHAM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:818-368-1234
Mailing Address - Street 1:18661 DEVONSHIRE ST
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91324
Mailing Address - Country:US
Mailing Address - Phone:818-368-1234
Mailing Address - Fax:818-363-3161
Practice Address - Street 1:18661 DEVONSHIRE ST
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91324
Practice Address - Country:US
Practice Address - Phone:818-368-1234
Practice Address - Fax:818-363-3161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT6899TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGSD000050Medicaid
CABY714AMedicare PIN
CAGSD000050Medicaid