Provider Demographics
NPI:1265674733
Name:D SCOTT SHETTLE OD PA
Entity Type:Organization
Organization Name:D SCOTT SHETTLE OD PA
Other - Org Name:SHETTLE FAMILY EYE CARE & EYE WEAR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST/OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:SHETTLE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:727-422-2940
Mailing Address - Street 1:1084 RIVERSIDE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:TARPON SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34688-8802
Mailing Address - Country:US
Mailing Address - Phone:727-422-2940
Mailing Address - Fax:
Practice Address - Street 1:4200 4TH ST N
Practice Address - Street 2:SUITE F
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33703-4735
Practice Address - Country:US
Practice Address - Phone:727-528-2015
Practice Address - Fax:727-528-2010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-30
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 2753332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6273020001Medicare NSC