Basic Information
| Provider Information | |||||||||
| NPI: | 1174293898 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SERENA SHAO OD PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14700 N FRANK LLOYD WRIGHT BLVD STE 155 | ||||||||
| Address2: | |||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852602046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807957970 | ||||||||
| FaxNumber: | 4807957078 | ||||||||
| Practice Location | |||||||||
| Address1: | 14700 N FRANK LLOYD WRIGHT BLVD STE 155 | ||||||||
| Address2: | |||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852602046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807957970 | ||||||||
| FaxNumber: | 4807957078 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2021 | ||||||||
| LastUpdateDate: | 04/25/2022 | ||||||||
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| AuthorizedOfficialLastName: | SHAO | ||||||||
| AuthorizedOfficialFirstName: | SERENA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4807957090 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | OD | ||||||||
| NPICertificationDate: | 04/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 440102 | 05 | AZ | MEDICAID |