Healthcare Provider Details

I. General information

NPI: 1609056852
Provider Name (Legal Business Name): TARA SUZANNE SHIELDS O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2007
Last Update Date: 11/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43927 15TH ST W
LANCASTER CA
93534-4758
US

IV. Provider business mailing address

43927 15TH ST W
LANCASTER CA
93534-4758
US

V. Phone/Fax

Practice location:
  • Phone: 661-948-6310
  • Fax: 611-948-6880
Mailing address:
  • Phone: 661-948-6310
  • Fax: 611-948-6880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number13444
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: