MEDICARE: LORI SHIN OD

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	4620	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457900102
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LORI SHIN OD

Provider Business Mailing Address
First Line	:	1430 NW HOYT ST APT 927
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97209-2286
Country	:	US
Telephone Number	:	301-328-6494
Fax Number	:

Provider Business Practice Location Address
First Line	:	2480 NE FREMONT ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97212-2509
Country	:	US
Telephone Number	:	503-284-3937
Fax Number	:

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

Provider Enumeration Date	:	09/05/2019
Last Update Date	:	07/06/2022

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Directions to “ LORI SHIN OD” Practice Location

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