Provider Demographics
NPI:1982663589
Name:SHAKE, STUART HENRY (OD)
Entity Type:Individual
Prefix:DR
First Name:STUART
Middle Name:HENRY
Last Name:SHAKE
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 1:2199 LEDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:IN
Mailing Address - Zip Code:47630-8057
Mailing Address - Country:US
Mailing Address - Phone:812-858-1997
Mailing Address - Fax:812-477-2152
Practice Address - Street 1:6614 LOGAN DR
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-8236
Practice Address - Country:US
Practice Address - Phone:812-477-6700
Practice Address - Fax:812-477-2152
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-22
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002521 B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN534680Medicare PIN