=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669489035
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SERENA SHIN O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2006
-----------------------------------------------------
Last Update Date | 10/04/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7 MILLER RD
-----------------------------------------------------
City | MAHOPAC
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10541-2219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-628-8788
-----------------------------------------------------
Fax | 845-628-9581
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 959
-----------------------------------------------------
City | MAHOPAC
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10541-0959
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-628-8788
-----------------------------------------------------
Fax | 845-628-9581
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | TUV005692-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------