Provider Demographics
NPI:1376778555
Name:DAVID SHIN OPTOMETRY
Entity type:Organization
Organization Name:DAVID SHIN OPTOMETRY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, OD
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:S
Authorized Official - Last Name:SHIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:909-980-5552
Mailing Address - Street 1:8003 ARCHIBALD AVE
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-2892
Mailing Address - Country:US
Mailing Address - Phone:909-980-5552
Mailing Address - Fax:909-568-2413
Practice Address - Street 1:8003 ARCHIBALD AVE
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-2892
Practice Address - Country:US
Practice Address - Phone:909-980-5552
Practice Address - Fax:909-568-2413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-18
Last Update Date:2009-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 12779T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0127790Medicaid
CASD0127790Medicaid