Provider Demographics
NPI:1528040243
Name:SPITTLER, SHANE (OD)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:
Last Name:SPITTLER
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 1:1530 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29115-3426
Mailing Address - Country:US
Mailing Address - Phone:803-535-2000
Mailing Address - Fax:
Practice Address - Street 1:1530 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-3426
Practice Address - Country:US
Practice Address - Phone:803-535-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-17
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1105152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD11057Medicaid