Provider Demographics
NPI:1629127519
Name:SHUHAM, ELLEN (OD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:SHUHAM
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 1:18661 DEVONSHIRE ST
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91324
Mailing Address - Country:US
Mailing Address - Phone:818-368-1234
Mailing Address - Fax:818-363-3161
Practice Address - Street 1:18661 DEVONSHIRE ST
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91324
Practice Address - Country:US
Practice Address - Phone:818-368-1234
Practice Address - Fax:818-363-3161
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT6899TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0068990Medicaid
CAWOP6899AMedicare PIN
T79392Medicare UPIN
CASD0068990Medicaid