Provider Demographics
NPI:1134118177
Name:SHIDLOFSKY, CHARLES (OD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:SHIDLOFSKY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7140 PRESTON RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-3278
Mailing Address - Country:US
Mailing Address - Phone:972-312-0177
Mailing Address - Fax:972-491-2020
Practice Address - Street 1:7140 PRESTON RD
Practice Address - Street 2:SUITE 300
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75024-3278
Practice Address - Country:US
Practice Address - Phone:972-312-0177
Practice Address - Fax:972-491-2020
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX3987TG152W00000X, 152WC0802X, 152WL0500X, 152WP0200X, 152WS0006X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXT15881Medicare UPIN
TX8B5647Medicare ID - Type UnspecifiedMEDICARE INDIVIDUAL NUMBE