Provider Demographics
NPI:1821077686
Name:WHEATLEY, SHAD L (OD)
Entity Type:Individual
Prefix:DR
First Name:SHAD
Middle Name:L
Last Name:WHEATLEY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:843 W STUART DR APT 7
Mailing Address - Street 2:
Mailing Address - City:HILLSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24343-1555
Mailing Address - Country:US
Mailing Address - Phone:276-728-9323
Mailing Address - Fax:276-728-0400
Practice Address - Street 1:843 W STUART DR APT 7
Practice Address - Street 2:
Practice Address - City:HILLSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24343-1555
Practice Address - Country:US
Practice Address - Phone:276-728-9323
Practice Address - Fax:276-728-0400
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-11
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001276152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1821077686Medicaid
VA1821077686Medicaid