Provider Demographics
NPI:1568410702
Name:MANGUIKIAN, SHAHAN A (OD)
Entity Type:Individual
Prefix:DR
First Name:SHAHAN
Middle Name:A
Last Name:MANGUIKIAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8061 SPYGLASSHILL RD SUITE 104A
Mailing Address - Street 2:
Mailing Address - City:VIERA
Mailing Address - State:FL
Mailing Address - Zip Code:32940
Mailing Address - Country:US
Mailing Address - Phone:321-751-6609
Mailing Address - Fax:321-751-6033
Practice Address - Street 1:8061 SPYGLASS HILL RD STE 104A
Practice Address - Street 2:
Practice Address - City:VIERA
Practice Address - State:FL
Practice Address - Zip Code:32940-8297
Practice Address - Country:US
Practice Address - Phone:321-751-6609
Practice Address - Fax:321-751-6033
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOP 2715152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL085917600Medicaid
FL085917600Medicaid
FLZO499ZMedicare PIN