Provider Demographics
NPI:1942482294
Name:DR SHANE B KEAST OD PA
Entity Type:Organization
Organization Name:DR SHANE B KEAST OD PA
Other - Org Name:DR SHANE B KEAST OD PA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROPRIOTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:BENJAMIN
Authorized Official - Last Name:KEAST
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:407-927-6022
Mailing Address - Street 1:1335 FAIRHAVEN CT
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32766-6697
Mailing Address - Country:US
Mailing Address - Phone:407-927-6022
Mailing Address - Fax:
Practice Address - Street 1:3817 E COLONIAL DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-5207
Practice Address - Country:US
Practice Address - Phone:407-897-3582
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3857152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU6560ZMedicare PIN