Healthcare Provider Details

I. General information

NPI: 1750596672
Provider Name (Legal Business Name): WILLIAM ABRAHAM SHAHEEN III O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 03/22/2021
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10531 W JEFFERSON AVE
RIVER ROUGE MI
48218-1306
US

IV. Provider business mailing address

8598 LAKE RD
GROSSE ILE MI
48138-1957
US

V. Phone/Fax

Practice location:
  • Phone: 313-841-5060
  • Fax:
Mailing address:
  • Phone: 734-675-2079
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901003733
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: