Provider Demographics
NPI:1285833624
Name:SHAFFER, MELISSA ANNA (OD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANNA
Last Name:SHAFFER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4118 W DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-3706
Mailing Address - Country:US
Mailing Address - Phone:320-251-2020
Mailing Address - Fax:
Practice Address - Street 1:4118 W DIVISION ST
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-3706
Practice Address - Country:US
Practice Address - Phone:320-251-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-16
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3125152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist