Provider Demographics
NPI:1760415947
Name:THEOBALD, SHANE (OD)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:THEOBALD
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 1:25500 N. NORTERRA PARKWAY, BLDG B
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085
Mailing Address - Country:US
Mailing Address - Phone:623-277-1000
Mailing Address - Fax:602-906-2789
Practice Address - Street 1:1717 W. CHANDLER BLVD
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224
Practice Address - Country:US
Practice Address - Phone:480-821-7565
Practice Address - Fax:480-821-4303
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1521152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZV09873Medicare UPIN
AZZ113618Medicare PIN