=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750596672
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILLIAM ABRAHAM SHAHEEN III O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2007
-----------------------------------------------------
Last Update Date | 03/22/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10531 W JEFFERSON AVE
-----------------------------------------------------
City | RIVER ROUGE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48218-1306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-841-5060
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8598 LAKE RD
-----------------------------------------------------
City | GROSSE ILE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48138-1957
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-675-2079
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 4901003733
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------