Provider Demographics
NPI:1548838352
Name:SHAKERI, TARA (OD)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:SHAKERI
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 1:500 TAMAL PLZ STE 503
Mailing Address - Street 2:
Mailing Address - City:CORTE MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:94925-1184
Mailing Address - Country:US
Mailing Address - Phone:415-925-9091
Mailing Address - Fax:
Practice Address - Street 1:500 TAMAL PLZ STE 503
Practice Address - Street 2:
Practice Address - City:CORTE MADERA
Practice Address - State:CA
Practice Address - Zip Code:94925-1184
Practice Address - Country:US
Practice Address - Phone:415-925-9091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-16
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA35603152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program