Provider Demographics
NPI:1720193188
Name:RUTH, SHIRLEY ELAINE (OD)
Entity Type:Individual
Prefix:DR
First Name:SHIRLEY
Middle Name:ELAINE
Last Name:RUTH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MS
Other - First Name:SHIRLEY
Other - Middle Name:RUTH
Other - Last Name:PIERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 44
Mailing Address - Street 2:
Mailing Address - City:BROOKVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15825-0044
Mailing Address - Country:US
Mailing Address - Phone:814-849-8875
Mailing Address - Fax:
Practice Address - Street 1:WALMART VISION CENTER #2540
Practice Address - Street 2:63 PERKINS ROAD
Practice Address - City:CLARION
Practice Address - State:PA
Practice Address - Zip Code:16214
Practice Address - Country:US
Practice Address - Phone:814-226-0909
Practice Address - Fax:814-226-0911
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000687152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARU187806Medicare ID - Type Unspecified