Provider Demographics
NPI:1013082056
Name:SHULTZ, HERBERT J (OD)
Entity Type:Individual
Prefix:DR
First Name:HERBERT
Middle Name:J
Last Name:SHULTZ
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 1:2400 SE BLVD UNIT A
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OH
Mailing Address - Zip Code:44460
Mailing Address - Country:US
Mailing Address - Phone:330-332-4501
Mailing Address - Fax:330-332-4540
Practice Address - Street 1:2400 SE BLVD UNIT A
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OH
Practice Address - Zip Code:44460
Practice Address - Country:US
Practice Address - Phone:330-332-4501
Practice Address - Fax:330-332-4540
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2008-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3439T880152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0441678Medicaid
OHSH0487291Medicare PIN
T47219Medicare UPIN
OH0670090001Medicare NSC