Provider Demographics
NPI:1740291442
Name:INGALLA, SHANIDA PATSAMARN (OD)
Entity type:Individual
Prefix:DR
First Name:SHANIDA
Middle Name:PATSAMARN
Last Name:INGALLA
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 1:32803 LAKE MEAD DR
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94555-1227
Mailing Address - Country:US
Mailing Address - Phone:510-441-1470
Mailing Address - Fax:
Practice Address - Street 1:3801 MIRANDA AVE
Practice Address - Street 2:OPTOMETRY #112
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304-1207
Practice Address - Country:US
Practice Address - Phone:650-493-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12182T152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation