Provider Demographics
NPI:1174530877
Name:SHEA, JACK CHIA (OD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:CHIA
Last Name:SHEA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2200 HARBOR BLVD
Mailing Address - Street 2:STE D130
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627
Mailing Address - Country:US
Mailing Address - Phone:949-642-7882
Mailing Address - Fax:949-642-7792
Practice Address - Street 1:2200 HARBOR BLVD
Practice Address - Street 2:STE D130
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627
Practice Address - Country:US
Practice Address - Phone:949-642-7882
Practice Address - Fax:949-642-7792
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11538TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U88369Medicare UPIN
CASD0115380Medicare ID - Type Unspecified
CAW0P11538AMedicare ID - Type Unspecified