Basic Information
| Provider Information | |||||||||
| NPI: | 1255398707 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHUJAAT | ||||||||
| FirstName: | HAJIRA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MOINUDDIN | ||||||||
| OtherFirstName: | HAJIRA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | O.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 160 BOSTON AVE | ||||||||
| Address2: | |||||||||
| City: | ALTAMONTE SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327014798 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078347776 | ||||||||
| FaxNumber: | 4078340973 | ||||||||
| Practice Location | |||||||||
| Address1: | 10000 WEST COLONIAL DR. | ||||||||
| Address2: | SUITE 183 | ||||||||
| City: | OCOEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347613434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078347776 | ||||||||
| FaxNumber: | 4078340973 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2006 | ||||||||
| LastUpdateDate: | 01/26/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPC 4096 | FL | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 621123200 | 05 | FL | MEDICAID |