Provider Demographics
NPI:1679582050
Name:TUBIELLO, SHAWN DAVID (OD)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:DAVID
Last Name:TUBIELLO
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 1:711 LAWN AVE
Mailing Address - Street 2:
Mailing Address - City:SELLERSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18960-1575
Mailing Address - Country:US
Mailing Address - Phone:215-257-8053
Mailing Address - Fax:215-257-2020
Practice Address - Street 1:711 LAWN AVE
Practice Address - Street 2:
Practice Address - City:SELLERSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18960-1575
Practice Address - Country:US
Practice Address - Phone:215-257-8053
Practice Address - Fax:215-257-2020
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000246152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP00120980OtherRAILROAD MEDICARE
PAP00120980OtherRAILROAD MEDICARE
PAU57939Medicare UPIN