Provider Demographics
NPI:1366439077
Name:RAVINE, SHELLI LYNN (OD)
Entity Type:Individual
Prefix:DR
First Name:SHELLI
Middle Name:LYNN
Last Name:RAVINE
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 1:1722 NEW BEDFORD RD
Mailing Address - Street 2:
Mailing Address - City:WALL TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:07719-3867
Mailing Address - Country:US
Mailing Address - Phone:732-971-1400
Mailing Address - Fax:732-974-2121
Practice Address - Street 1:1722 NEW BEDFORD RD
Practice Address - Street 2:
Practice Address - City:WALL TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:07719-3867
Practice Address - Country:US
Practice Address - Phone:732-971-1400
Practice Address - Fax:732-974-2121
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ270A00453000152W00000X
NJ27T000033700152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ102497VJWMedicare PIN
U26779Medicare UPIN