Provider Demographics
NPI:1346391588
Name:SHAPIRO, ELLIOTT MARVIN (OD)
Entity Type:Individual
Prefix:
First Name:ELLIOTT
Middle Name:MARVIN
Last Name:SHAPIRO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4353 LA JOLLA VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122-1259
Mailing Address - Country:US
Mailing Address - Phone:858-622-2165
Mailing Address - Fax:858-622-2177
Practice Address - Street 1:4353 LA JOLLA VILLAGE DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122-1259
Practice Address - Country:US
Practice Address - Phone:858-622-2165
Practice Address - Fax:858-622-2177
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7342152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWY007TMedicare ID - Type Unspecified
CAT90745Medicare UPIN