Healthcare Provider Details

I. General information

NPI: 1922190321
Provider Name (Legal Business Name): SUSAN M. SHIN O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2006
Last Update Date: 01/09/2025
Certification Date: 01/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2575 YORBA LINDA BLVD
FULLERTON CA
92831-1699
US

IV. Provider business mailing address

2575 SANDPEBBLE LN
BREA CA
92821-4500
US

V. Phone/Fax

Practice location:
  • Phone: 714-449-7401
  • Fax:
Mailing address:
  • Phone: 562-715-6900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number11211
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number11211T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: