Provider Demographics
NPI:1093970444
Name:JACK SHIH OD A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:JACK SHIH OD A PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHUN-CHIEH
Authorized Official - Middle Name:JACK
Authorized Official - Last Name:SHIH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:626-810-0858
Mailing Address - Street 1:1679 S AZUSA AVE
Mailing Address - Street 2:
Mailing Address - City:HACIENDA HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91745-3832
Mailing Address - Country:US
Mailing Address - Phone:626-810-0858
Mailing Address - Fax:626-810-1308
Practice Address - Street 1:1679 S AZUSA AVE
Practice Address - Street 2:
Practice Address - City:HACIENDA HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:91745-3832
Practice Address - Country:US
Practice Address - Phone:626-810-0858
Practice Address - Fax:626-810-1308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-25
Last Update Date:2020-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13565152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADM215AMedicare PIN