Provider Demographics
NPI:1699818013
Name:HARTMAN, SHANE D (OD)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:D
Last Name:HARTMAN
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 1:2310 S MARION RD
Mailing Address - Street 2:STE 140
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57106-1144
Mailing Address - Country:US
Mailing Address - Phone:605-361-2058
Mailing Address - Fax:
Practice Address - Street 1:1621 S MINNESOTA AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1743
Practice Address - Country:US
Practice Address - Phone:605-328-9200
Practice Address - Fax:605-328-9201
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD586152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD42581OtherSPECTERA
SD9201352Medicaid
SD42581OtherSPECTERA
U77757Medicare UPIN
SD42581OtherSPECTERA