Provider Demographics
NPI:1962667055
Name:CLABORN, SHANE LEE (OD)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:LEE
Last Name:CLABORN
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 1:4250 NW CACHE RD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-3606
Mailing Address - Country:US
Mailing Address - Phone:580-248-0061
Mailing Address - Fax:580-248-0074
Practice Address - Street 1:4250 NW CACHE RD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-3606
Practice Address - Country:US
Practice Address - Phone:580-248-0061
Practice Address - Fax:580-248-0074
Is Sole Proprietor?:No
Enumeration Date:2008-07-28
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2552152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200208350AMedicaid
OK200208350AMedicaid
OK6390520001Medicare NSC