Provider Demographics
NPI:1336865526
Name:SHAHIDI, JACOB (OD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:SHAHIDI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1091 BIG SUR DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95120-3415
Mailing Address - Country:US
Mailing Address - Phone:408-466-0822
Mailing Address - Fax:
Practice Address - Street 1:904 CEDAR ST
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-3802
Practice Address - Country:US
Practice Address - Phone:831-426-1050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-18
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35336152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist