Provider Demographics
NPI:1124462452
Name:JENNIFER J. SHABA O.D. P.L.L.C
Entity type:Organization
Organization Name:JENNIFER J. SHABA O.D. P.L.L.C
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:SHABA
Authorized Official - Last Name:YALLDO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:585-994-4499
Mailing Address - Street 1:5600 W MAPLE RD STE A120
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3782
Mailing Address - Country:US
Mailing Address - Phone:248-413-8030
Mailing Address - Fax:
Practice Address - Street 1:5600 W MAPLE RD STE A120
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3782
Practice Address - Country:US
Practice Address - Phone:248-413-8030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-17
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004524152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty