Provider Demographics
NPI:1962840264
Name:SHIAU, JEFFERY ROBERT (OD)
Entity type:Individual
Prefix:
First Name:JEFFERY
Middle Name:ROBERT
Last Name:SHIAU
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801-3552
Mailing Address - Country:US
Mailing Address - Phone:626-282-3115
Mailing Address - Fax:626-282-3463
Practice Address - Street 1:2 W MAIN ST
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91801-3552
Practice Address - Country:US
Practice Address - Phone:626-282-3115
Practice Address - Fax:626-282-3463
Is Sole Proprietor?:No
Enumeration Date:2013-06-07
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14614152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1962840264Medicaid
CA1962840264Medicaid