Provider Demographics
NPI:1013457464
Name:JOSEPH, SHAWN M
Entity Type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:M
Last Name:JOSEPH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6345 BALBOA BLVD STE 250
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-5236
Mailing Address - Country:US
Mailing Address - Phone:818-344-3937
Mailing Address - Fax:818-344-1229
Practice Address - Street 1:6345 BALBOA BLVD STE 250
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-5236
Practice Address - Country:US
Practice Address - Phone:818-344-3937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-06
Last Update Date:2022-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC5324152W00000X
CA33802152WS0006X, 152WV0400X, 152WP0200X
CAOPT33802152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometrist
No152WS0006XEye and Vision Services ProvidersOptometristSports VisionGroup - Single Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty