Healthcare Provider Details

I. General information

NPI: 1568765352
Provider Name (Legal Business Name): JAMES S SHIN OD A PROFESSIONAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2010
Last Update Date: 11/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1556 MERIDIAN AVE
SAN JOSE CA
95125-5319
US

IV. Provider business mailing address

1556 MERIDIAN AVE
SAN JOSE CA
95125-5319
US

V. Phone/Fax

Practice location:
  • Phone: 408-445-2020
  • Fax: 408-445-2712
Mailing address:
  • Phone: 408-445-2020
  • Fax: 408-445-2712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number11745T
License Number StateCA

VIII. Authorized Official

Name: JAMES S SHIN
Title or Position: OWNER
Credential: OD
Phone: 408-445-2020