Provider Demographics
NPI:1639721392
Name:TIBILETTI, SHANE LUCAS (OD)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:LUCAS
Last Name:TIBILETTI
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 1:1101 MELBOURNE RD # 217
Mailing Address - Street 2:
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76053-6205
Mailing Address - Country:US
Mailing Address - Phone:817-284-0798
Mailing Address - Fax:
Practice Address - Street 1:1101 MELBOURNE RD # 217
Practice Address - Street 2:
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76053-6205
Practice Address - Country:US
Practice Address - Phone:817-284-0798
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-12
Last Update Date:2019-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9738T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist