Provider Demographics
NPI:1497034342
Name:BORREGO, SHANNON YVONNE (OD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:YVONNE
Last Name:BORREGO
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:PO BOX 38
Mailing Address - Street 2:
Mailing Address - City:SACATON
Mailing Address - State:AZ
Mailing Address - Zip Code:85147-0001
Mailing Address - Country:US
Mailing Address - Phone:602-528-1200
Mailing Address - Fax:602-528-1255
Practice Address - Street 1:483 W. SEED FARM RD
Practice Address - Street 2:
Practice Address - City:SACATON
Practice Address - State:AZ
Practice Address - Zip Code:85147
Practice Address - Country:US
Practice Address - Phone:602-528-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-10
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1825152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ640201Medicaid
AZ640201Medicaid