Provider Demographics
NPI:1558419804
Name:SHALOM, DARA ANISSA (OD)
Entity Type:Individual
Prefix:
First Name:DARA
Middle Name:ANISSA
Last Name:SHALOM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:DARA
Other - Middle Name:ANISSA
Other - Last Name:GREENBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:41 W PUTNAM AVE
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06830-5300
Mailing Address - Country:US
Mailing Address - Phone:203-869-2255
Mailing Address - Fax:203-869-0333
Practice Address - Street 1:345 E 37TH ST
Practice Address - Street 2:301
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-3256
Practice Address - Country:US
Practice Address - Phone:800-984-2020
Practice Address - Fax:203-869-0333
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYT006573152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYT006573OtherSTATE LICENSE