Provider Demographics
NPI:1114041787
Name:SHESTACK, DONALD HARRY (OD)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:HARRY
Last Name:SHESTACK
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 1:102 SPRUCE DR
Mailing Address - Street 2:
Mailing Address - City:MCMURRAY
Mailing Address - State:PA
Mailing Address - Zip Code:15317-3538
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 S HILLS VLG
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15241-1416
Practice Address - Country:US
Practice Address - Phone:412-833-3334
Practice Address - Fax:412-833-1809
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEP-008557152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA00889842Medicaid
PASH289048OtherPA. BLUE SHIELD
PAU08084Medicare UPIN
PA00889842Medicaid