Provider Demographics
NPI:1225146160
Name:VOGEL, SHANE NICHOLAS (OD)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:NICHOLAS
Last Name:VOGEL
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 1:2325 W 57TH ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-5046
Mailing Address - Country:US
Mailing Address - Phone:605-275-6100
Mailing Address - Fax:605-275-6105
Practice Address - Street 1:2325 W 57TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-5046
Practice Address - Country:US
Practice Address - Phone:605-275-6100
Practice Address - Fax:605-275-6105
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02358152W00000X
SD685152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA421497917OtherCOMMERCIAL & OTHER STATES
IAA004235OtherCHAMPUS
IA0218339Medicaid
IA18020OtherWELLMARK
IACH2873Medicare PIN
IA4001120003Medicare NSC
IAV10892Medicare UPIN
IA18020Medicare PIN