Provider Demographics
NPI:1376039602
Name:SHIN, MICHELLE (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:
Last Name:SHIN
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 1:1200 ARTESIA BLVD.
Mailing Address - Street 2:STE 100
Mailing Address - City:HERMOSA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90254
Mailing Address - Country:US
Mailing Address - Phone:310-933-5035
Mailing Address - Fax:
Practice Address - Street 1:1200 ARTESIA BLVD.
Practice Address - Street 2:STE 100
Practice Address - City:HERMOSA BEACH
Practice Address - State:CA
Practice Address - Zip Code:90254
Practice Address - Country:US
Practice Address - Phone:310-933-5035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-10
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT33924TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist