Provider Demographics
NPI:1275802662
Name:DR. KUNAL T. SHAH O.D. INC.
Entity Type:Organization
Organization Name:DR. KUNAL T. SHAH O.D. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KUNAL
Authorized Official - Middle Name:T
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:562-866-2020
Mailing Address - Street 1:17139 BELLFLOWER BLVD
Mailing Address - Street 2:# 101
Mailing Address - City:BELLFLOWER
Mailing Address - State:CA
Mailing Address - Zip Code:90706-5943
Mailing Address - Country:US
Mailing Address - Phone:562-866-2020
Mailing Address - Fax:562-920-3336
Practice Address - Street 1:17139 BELLFLOWER BLVD
Practice Address - Street 2:# 101
Practice Address - City:BELLFLOWER
Practice Address - State:CA
Practice Address - Zip Code:90706-5943
Practice Address - Country:US
Practice Address - Phone:562-866-2020
Practice Address - Fax:562-920-3336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-14
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12356T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1275802662Medicaid
CAFW044AMedicare PIN