Provider Demographics
NPI:1598751430
Name:SHAUNETTE, GINA MARIA (OD)
Entity type:Individual
Prefix:DR
First Name:GINA
Middle Name:MARIA
Last Name:SHAUNETTE
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 1:5520 WHITTIER BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90022-4104
Mailing Address - Country:US
Mailing Address - Phone:323-728-2708
Mailing Address - Fax:323-728-0096
Practice Address - Street 1:5520 WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022-4104
Practice Address - Country:US
Practice Address - Phone:323-728-2708
Practice Address - Fax:323-728-0096
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10415T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0104150Medicaid
CAWOP10415AMedicare ID - Type UnspecifiedINDIVIDUAL NO. IN GROUP
CASD0104150Medicaid