Healthcare Provider Details

I. General information

NPI: 1114378601
Provider Name (Legal Business Name): BEX SHAHI O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2016
Last Update Date: 02/09/2024
Certification Date: 02/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2282 NW TROOST ST STE 104
ROSEBURG OR
97471-6072
US

IV. Provider business mailing address

1277 NE LINCOLN ST
ROSEBURG OR
97470-2181
US

V. Phone/Fax

Practice location:
  • Phone: 541-672-7428
  • Fax:
Mailing address:
  • Phone: 940-676-6243
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTA2550
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: