Provider Demographics
NPI:1821084625
Name:SHELLITO, ROBERT J (DPM)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:J
Last Name:SHELLITO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 70
Mailing Address - Street 2:
Mailing Address - City:HUBBARD
Mailing Address - State:OH
Mailing Address - Zip Code:44425-0070
Mailing Address - Country:US
Mailing Address - Phone:330-392-2700
Mailing Address - Fax:330-392-2707
Practice Address - Street 1:1543 E MARKET ST
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44483-6639
Practice Address - Country:US
Practice Address - Phone:330-392-2700
Practice Address - Fax:330-392-2707
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-27
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36003129S213E00000X
PASC005955213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2154163Medicaid
PA101757359 0002Medicaid
PA124702Medicare PIN
OHRO9375401Medicare PIN
PA101757359 0002Medicaid
OHU78081Medicare UPIN