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General NPI Number Information
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NPI Number | 1902327240
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Entity Type | Individual
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Provider Name | PROTIVA SHOOPROVA KHAN OD
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Gender | Female
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Dates
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Enumeration Date | 06/27/2017
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Last Update Date | 11/01/2021
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Provider Practice Location Address
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Address Line | 5192 HOSPITAL ROAD
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City | MARIPOSA
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State | CA
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Zip | 95338
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Country | US
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Telephone | 209-742-6144
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Fax |
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Provider Business Mailing Address
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Address Line | 2912 WILLOWBROOK DR APT 3
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City | MERCED
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State | CA
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Zip | 95348-1301
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Country | US
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Telephone | 213-820-6350
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | TUV008592-1
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 34680
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License Number State | CA
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