Provider Demographics
NPI:1467429969
Name:SHANK, ROBERT G (OD TMOD TPA)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:G
Last Name:SHANK
Suffix:
Gender:M
Credentials:OD TMOD TPA
Other - Prefix:
Other - First Name:R
Other - Middle Name:G
Other - Last Name:SHANK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:801 COMMERCIAL
Mailing Address - Street 2:PO BOX 1155
Mailing Address - City:EMPORIA
Mailing Address - State:KS
Mailing Address - Zip Code:66801
Mailing Address - Country:US
Mailing Address - Phone:620-342-2109
Mailing Address - Fax:
Practice Address - Street 1:801 COMMERCIAL
Practice Address - Street 2:
Practice Address - City:EMPORIA
Practice Address - State:KS
Practice Address - Zip Code:66801
Practice Address - Country:US
Practice Address - Phone:620-342-2109
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS10132152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS5263OtherBCBS
8354Medicare UPIN
KS005263Medicare ID - Type Unspecified