Provider Demographics
NPI:1922173251
Name:SHETZLINE, RICHARD MICHAEL (OD)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:MICHAEL
Last Name:SHETZLINE
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 1:4423 RTE 130 SOUTH
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08016
Mailing Address - Country:US
Mailing Address - Phone:609-386-0202
Mailing Address - Fax:609-386-5927
Practice Address - Street 1:4423 RTE 130 SOUTH
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08016
Practice Address - Country:US
Practice Address - Phone:609-386-0202
Practice Address - Fax:609-386-5927
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ5549152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8757501Medicaid
U74162Medicare UPIN
NJ024780AA2Medicare ID - Type Unspecified