Provider Demographics
NPI:1568736890
Name:KIKAWA, SHINE (OD)
Entity Type:Individual
Prefix:DR
First Name:SHINE
Middle Name:
Last Name:KIKAWA
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 1:1610 S RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-7708
Mailing Address - Country:US
Mailing Address - Phone:909-421-2020
Mailing Address - Fax:
Practice Address - Street 1:1610 S RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-7708
Practice Address - Country:US
Practice Address - Phone:909-421-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-05
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT14329TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist