Provider Demographics
NPI:1447200456
Name:SHUFELT, HEIDI ANNE (OD)
Entity Type:Individual
Prefix:DR
First Name:HEIDI
Middle Name:ANNE
Last Name:SHUFELT
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 1:4801 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53406-4219
Mailing Address - Country:US
Mailing Address - Phone:262-637-3733
Mailing Address - Fax:262-637-0752
Practice Address - Street 1:4801 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406-4219
Practice Address - Country:US
Practice Address - Phone:262-637-3733
Practice Address - Fax:262-637-0752
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2554152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38595900Medicaid
WI38595900Medicaid
WI87846Medicare ID - Type Unspecified