Provider Demographics
NPI:1659477339
Name:SHUKE, WILLIAM BLAINE (OD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:BLAINE
Last Name:SHUKE
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 1:311 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:PA
Mailing Address - Zip Code:15537-7022
Mailing Address - Country:US
Mailing Address - Phone:814-623-1969
Mailing Address - Fax:814-623-5590
Practice Address - Street 1:311 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:PA
Practice Address - Zip Code:15537-7022
Practice Address - Country:US
Practice Address - Phone:814-623-1969
Practice Address - Fax:814-623-5590
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000761152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016242330004Medicaid
PA0016242330004Medicaid
PA172508Medicare ID - Type Unspecified