1265674733 NPI number — D SCOTT SHETTLE OD PA

Table of content: (NPI 1265674733)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265674733 NPI number — D SCOTT SHETTLE OD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
D SCOTT SHETTLE OD PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SHETTLE FAMILY EYE CARE & EYE WEAR
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265674733
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/24/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1084 RIVERSIDE RIDGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TARPON SPRINGS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34688-8802
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-422-2940
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4200 4TH ST N
Provider Second Line Business Practice Location Address:
SUITE F
Provider Business Practice Location Address City Name:
ST PETERSBURG
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33703-4735
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-528-2015
Provider Business Practice Location Address Fax Number:
727-528-2010
Provider Enumeration Date:
03/30/2009

Additional Information

Authorized Official

Authorized Official Last Name:
SHETTLE
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
SCOTT
Authorized Official Title or Position:
OPTOMETRIST/OWNER/PRESIDENT
Authorized Official Telephone Number:
727-422-2940

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X , with the licence number:  OPC 2753 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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