Provider Demographics
NPI:1598996399
Name:MCCORMICK, SHAELAN (OD)
Entity Type:Individual
Prefix:DR
First Name:SHAELAN
Middle Name:
Last Name:MCCORMICK
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 1:300 PLAZA CT
Mailing Address - Street 2:SUITE A
Mailing Address - City:EAST STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18301-8260
Mailing Address - Country:US
Mailing Address - Phone:570-421-8842
Mailing Address - Fax:570-476-5842
Practice Address - Street 1:100 COMMUNITY DR
Practice Address - Street 2:SUITE 204A
Practice Address - City:TOBYHANNA
Practice Address - State:PA
Practice Address - Zip Code:18466-8985
Practice Address - Country:US
Practice Address - Phone:570-895-4550
Practice Address - Fax:570-895-4461
Is Sole Proprietor?:No
Enumeration Date:2009-07-29
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG002244152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1023389000001Medicaid
161545F88Medicare PIN