Provider Demographics
NPI:1669523734
Name:KHAN, SHAMEEM BANU (OD)
Entity type:Individual
Prefix:
First Name:SHAMEEM
Middle Name:BANU
Last Name:KHAN
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 1:13768 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
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10458152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU51710Medicare UPIN
CAWOP104581Medicare ID - Type Unspecified