Provider Demographics
NPI:1477612273
Name:SHIRTS, OWEN M (OD)
Entity Type:Individual
Prefix:DR
First Name:OWEN
Middle Name:M
Last Name:SHIRTS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:838 S WOODRUFF AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-5296
Mailing Address - Country:US
Mailing Address - Phone:208-523-3937
Mailing Address - Fax:208-523-4251
Practice Address - Street 1:838 S WOODRUFF AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-5296
Practice Address - Country:US
Practice Address - Phone:208-523-3937
Practice Address - Fax:208-523-4251
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP716152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDV7269OtherBLUE CROSS
ID002609700Medicaid
ID410041059OtherMEDICARE RAILROAD
ID000010015228OtherBLUE SHIELD
IDCS9984OtherCONTROLLED SUBSTANCE
IDCS9984OtherCONTROLLED SUBSTANCE
ID1591581Medicare ID - Type Unspecified
ID410041059OtherMEDICARE RAILROAD
IDMS0964278OtherDEA