MEDICARE: KEITH SHIMIZU 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	803	NV

General Provider Information

NPI Number	:	1568878163
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEITH SHIMIZU O.D.

Provider Business Mailing Address
First Line	:	7361 W LAKE MEAD BLVD STE 104
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-1040
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7361 W LAKE MEAD BLVD STE 104
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-1040
Country	:	US
Telephone Number	:	702-733-6764
Fax Number	:

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

Provider Enumeration Date	:	07/03/2014
Last Update Date	:	09/18/2014

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