Provider Demographics
NPI:1275611246
Name:SHOULDICE, WILLIAM ROY (OD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:ROY
Last Name:SHOULDICE
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:PO BOX 1665
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49734-5665
Mailing Address - Country:US
Mailing Address - Phone:989-732-6455
Mailing Address - Fax:989-732-1102
Practice Address - Street 1:350 W NORTH ST
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-1525
Practice Address - Country:US
Practice Address - Phone:989-732-6455
Practice Address - Fax:989-732-1102
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003939152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0585020001OtherADMINASTAR
MI410037242OtherRAILROAD MEDICARE
MI900A665060OtherBCBS
MI0M69410OtherMEDICARE PLUS BLUE
MI3493121Medicaid
MI0M69410OtherMEDICARE PLUS BLUE