=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598751430
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GINA MARIA SHAUNETTE O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2005
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5520 WHITTIER BLVD
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90022-4104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-728-2708
-----------------------------------------------------
Fax | 323-728-0096
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5520 WHITTIER BLVD
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90022-4104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-728-2708
-----------------------------------------------------
Fax | 323-728-0096
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 10415T
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------