MEDICARE: ELIZABETH SHIPMAN O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	12188T	CA

General Provider Information

NPI Number	:	1114478468
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH SHIPMAN O.D.

Provider Business Mailing Address
First Line	:	3700 SAN PABLO AVE
Second Line	:	UNIT 5
City	:	HERCULES
State	:	CA
Zip	:	94547-3968
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3700 SAN PABLO AVE
Second Line	:	UNIT 5
City	:	HERCULES
State	:	CA
Zip	:	94547-3968
Country	:	US
Telephone Number	:	510-741-9900
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/21/2016
Last Update Date	:	10/21/2016

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