Provider Demographics
NPI:1174175129
Name:MA, SHAN (OD)
Entity type:Individual
Prefix:
First Name:SHAN
Middle Name:
Last Name:MA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1364 WORCESTER ST
Mailing Address - Street 2:
Mailing Address - City:NATICK
Mailing Address - State:MA
Mailing Address - Zip Code:01760-1514
Mailing Address - Country:US
Mailing Address - Phone:508-655-8127
Mailing Address - Fax:
Practice Address - Street 1:1364 WORCESTER ST
Practice Address - Street 2:
Practice Address - City:NATICK
Practice Address - State:MA
Practice Address - Zip Code:01760-1514
Practice Address - Country:US
Practice Address - Phone:508-655-8127
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-10
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5358152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist