Provider Demographics
NPI:1184889388
Name:SHEDLOCK, JOHN JOSEPH (OD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:JOSEPH
Last Name:SHEDLOCK
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 1:612 CLARA ST SUITE 1
Mailing Address - Street 2:
Mailing Address - City:HOUTZDALE
Mailing Address - State:PA
Mailing Address - Zip Code:16651-9510
Mailing Address - Country:US
Mailing Address - Phone:814-378-7700
Mailing Address - Fax:814-378-7704
Practice Address - Street 1:612 CLARA ST STE 1
Practice Address - Street 2:
Practice Address - City:HOUTZDALE
Practice Address - State:PA
Practice Address - Zip Code:16651-1115
Practice Address - Country:US
Practice Address - Phone:814-378-7700
Practice Address - Fax:814-378-7704
Is Sole Proprietor?:No
Enumeration Date:2008-07-28
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG002084152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102260899 0001Medicaid
PA102260899 0001Medicaid