Provider Demographics
NPI:1356654180
Name:SHEHATA, NOHA M (OD)
Entity Type:Individual
Prefix:
First Name:NOHA
Middle Name:M
Last Name:SHEHATA
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 1:28356 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-1434
Mailing Address - Country:US
Mailing Address - Phone:310-831-0841
Mailing Address - Fax:
Practice Address - Street 1:28356 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:RANCHO PALOS VERDES
Practice Address - State:CA
Practice Address - Zip Code:90275-1434
Practice Address - Country:US
Practice Address - Phone:504-232-8191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-21
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1588621-T152W00000X
TX7612TG152WC0802X
CA15185TLG152WC0802X
PAOEG002584152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB137287Medicare PIN
CACB260529Medicare PIN
PA332470YXXHMedicare PIN