Provider Demographics
NPI:1346664679
Name:SHOR, YANISLAV (LDO)
Entity Type:Individual
Prefix:
First Name:YANISLAV
Middle Name:
Last Name:SHOR
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3745 NE 163RD ST
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33160-4104
Mailing Address - Country:US
Mailing Address - Phone:305-940-0200
Mailing Address - Fax:305-944-0222
Practice Address - Street 1:3745 NE 163RD ST
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33160-4104
Practice Address - Country:US
Practice Address - Phone:305-940-0200
Practice Address - Fax:305-944-0222
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-06
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO5936156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician