Provider Demographics
NPI:1184698318
Name:LEBEAU, SHANE OTTO (MD)
Entity type:Individual
Prefix:DR
First Name:SHANE
Middle Name:OTTO
Last Name:LEBEAU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MEYRAN AVE
Mailing Address - Street 2:SUITE 318
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15213-3305
Mailing Address - Country:US
Mailing Address - Phone:412-383-1650
Mailing Address - Fax:
Practice Address - Street 1:200 MEYRAN AVE
Practice Address - Street 2:SUITE 318
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15213-3305
Practice Address - Country:US
Practice Address - Phone:412-383-1650
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD421951174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA088778Medicare ID - Type Unspecified
PAH80061Medicare UPIN