Provider Demographics
NPI:1912205816
Name:DR SHAMEEM KHAN OPTOMETRIST INC
Entity Type:Organization
Organization Name:DR SHAMEEM KHAN OPTOMETRIST INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAMEEM
Authorized Official - Middle Name:BANU
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:909-627-2020
Mailing Address - Street 1:13768 ROSWELL AVE STE 208
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-1405
Mailing Address - Country:US
Mailing Address - Phone:909-627-2020
Mailing Address - Fax:909-627-2021
Practice Address - Street 1:13768 ROSWELL AVE STE 208
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-1405
Practice Address - Country:US
Practice Address - Phone:909-627-2020
Practice Address - Fax:909-627-2021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-02
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAES258AMedicare PIN