Provider Demographics
NPI:1669489035
Name:SHIN, SERENA (OD)
Entity Type:Individual
Prefix:
First Name:SERENA
Middle Name:
Last Name:SHIN
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:PO BOX 959
Mailing Address - Street 2:
Mailing Address - City:MAHOPAC
Mailing Address - State:NY
Mailing Address - Zip Code:10541-0959
Mailing Address - Country:US
Mailing Address - Phone:845-628-8788
Mailing Address - Fax:845-628-9581
Practice Address - Street 1:7 MILLER RD
Practice Address - Street 2:
Practice Address - City:MAHOPAC
Practice Address - State:NY
Practice Address - Zip Code:10541-2219
Practice Address - Country:US
Practice Address - Phone:845-628-8788
Practice Address - Fax:845-628-9581
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV005692-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7290443OtherAETNA
NY2284264OtherUNITED HEALTHCARE
NYP2803098OtherOXFORD
NY4C5916OtherHEALTHNET
NYC279H1OtherEMPIRE BLUE SHIELD
NYMVPOther393760
NYC271G1Medicare PIN
NYP2803098OtherOXFORD