Provider Demographics
NPI:1225133713
Name:SHAFER, J LARRY (OD)
Entity Type:Individual
Prefix:DR
First Name:J LARRY
Middle Name:
Last Name:SHAFER
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 1:191 WINSTON AVE NE
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-2655
Mailing Address - Country:US
Mailing Address - Phone:330-499-6638
Mailing Address - Fax:
Practice Address - Street 1:511 E MAPLE ST
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-2600
Practice Address - Country:US
Practice Address - Phone:330-499-6638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2839152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0470491Medicare ID - Type Unspecified