Provider Demographics
NPI:1386833192
Name:CHARLES SHIDLOFSKY O.D., P.A.
Entity Type:Organization
Organization Name:CHARLES SHIDLOFSKY O.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:SHIDLOFSKY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:972-312-0177
Mailing Address - Street 1:5934 W PARKER RD
Mailing Address - Street 2:STE. 500
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-6409
Mailing Address - Country:US
Mailing Address - Phone:972-312-0177
Mailing Address - Fax:972-312-0134
Practice Address - Street 1:5934 W PARKER RD
Practice Address - Street 2:STE. 500
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-6409
Practice Address - Country:US
Practice Address - Phone:972-312-0177
Practice Address - Fax:972-312-0134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-17
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3987TG152W00000X, 152WC0802X, 152WL0500X, 152WP0200X, 152WS0006X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Single Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Single Specialty
No152WS0006XEye and Vision Services ProvidersOptometristSports VisionGroup - Single Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
00312WMedicare PIN
T15881Medicare UPIN