Provider Demographics
NPI:1457900102
Name:SHIN, LORI (OD)
Entity Type:Individual
Prefix:
First Name:LORI
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 1:1430 NW HOYT ST APT 927
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-2286
Mailing Address - Country:US
Mailing Address - Phone:301-328-6494
Mailing Address - Fax:
Practice Address - Street 1:2480 NE FREMONT ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-2509
Practice Address - Country:US
Practice Address - Phone:503-284-3937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-05
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4620152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500805683Medicaid