Provider Demographics
NPI:1497031124
Name:FRERICHS, SHANE WILLIAM (OD)
Entity type:Individual
Prefix:DR
First Name:SHANE
Middle Name:WILLIAM
Last Name:FRERICHS
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 1:2438 RESEARCH PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-1094
Mailing Address - Country:US
Mailing Address - Phone:719-599-5083
Mailing Address - Fax:195-993-2917
Practice Address - Street 1:2438 RESEARCH PKWY STE 200
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-1094
Practice Address - Country:US
Practice Address - Phone:719-599-5083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-26
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1660152W00000X
COOPT 0002957152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist