Provider Demographics
NPI:1710074786
Name:HALLSTROM, SHELDON L (OD)
Entity Type:Individual
Prefix:
First Name:SHELDON
Middle Name:L
Last Name:HALLSTROM
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 1:3300 CHAMBERS RD
Mailing Address - Street 2:SUITE 5086
Mailing Address - City:HORSEHEADS
Mailing Address - State:NY
Mailing Address - Zip Code:14845-1404
Mailing Address - Country:US
Mailing Address - Phone:607-739-0383
Mailing Address - Fax:607-739-5362
Practice Address - Street 1:3300 CHAMBERS RD
Practice Address - Street 2:SUITE 5086
Practice Address - City:HORSEHEADS
Practice Address - State:NY
Practice Address - Zip Code:14845-1404
Practice Address - Country:US
Practice Address - Phone:607-739-0383
Practice Address - Fax:607-739-5362
Is Sole Proprietor?:No
Enumeration Date:2006-10-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYT004363152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U11965Medicare UPIN
52557BMedicare ID - Type Unspecified