Provider Demographics
NPI:1578672234
Name:BAGDASSAR, SHAKEH J (OD)
Entity Type:Individual
Prefix:DR
First Name:SHAKEH
Middle Name:J
Last Name:BAGDASSAR
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 1:1101 N PACIFIC AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91202-3250
Mailing Address - Country:US
Mailing Address - Phone:818-243-1111
Mailing Address - Fax:818-243-1375
Practice Address - Street 1:1101 N PACIFIC AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91202-3250
Practice Address - Country:US
Practice Address - Phone:818-243-1111
Practice Address - Fax:818-243-1375
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9792T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0097920Medicaid
CASD0097920Medicaid
CADB039AMedicare PIN