Provider Demographics
NPI:1447399662
Name:SHADID, PAULA D (OD)
Entity Type:Individual
Prefix:DR
First Name:PAULA
Middle Name:D
Last Name:SHADID
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 1:987 GOLF COURSE DR
Mailing Address - Street 2:
Mailing Address - City:ROHNERT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94928-1892
Mailing Address - Country:US
Mailing Address - Phone:707-584-1233
Mailing Address - Fax:
Practice Address - Street 1:987 GOLF COURSE DR
Practice Address - Street 2:
Practice Address - City:ROHNERT PARK
Practice Address - State:CA
Practice Address - Zip Code:94928-1892
Practice Address - Country:US
Practice Address - Phone:707-584-1233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 8025 TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA13102OtherMES
CASD0080250Medicaid
CAZZZ15487ZMedicare ID - Type Unspecified
CAU28968Medicare UPIN
CASD0080250Medicaid