Provider Demographics
NPI:1609003763
Name:MAAG, SHANE MICHAEL (OD)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:MICHAEL
Last Name:MAAG
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 1:1518 N PERRY ST
Mailing Address - Street 2:
Mailing Address - City:OTTAWA
Mailing Address - State:OH
Mailing Address - Zip Code:45875-1167
Mailing Address - Country:US
Mailing Address - Phone:419-523-5670
Mailing Address - Fax:419-523-4025
Practice Address - Street 1:1518 N PERRY ST
Practice Address - Street 2:
Practice Address - City:OTTAWA
Practice Address - State:OH
Practice Address - Zip Code:45875-1167
Practice Address - Country:US
Practice Address - Phone:419-523-5670
Practice Address - Fax:419-523-4025
Is Sole Proprietor?:No
Enumeration Date:2009-06-16
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5882152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist