Provider Demographics
NPI:1649356775
Name:PHILIP L. SHETTLE D.O., P.A.
Entity type:Organization
Organization Name:PHILIP L. SHETTLE D.O., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:L
Authorized Official - Last Name:SHETTLE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:727-581-8755
Mailing Address - Street 1:670 N. CLEARWATER - LARGO ROAD
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33770-2377
Mailing Address - Country:US
Mailing Address - Phone:727-581-8755
Mailing Address - Fax:727-581-8756
Practice Address - Street 1:670 N. CLEARWATER - LARGO ROAD
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33770-2377
Practice Address - Country:US
Practice Address - Phone:727-581-8755
Practice Address - Fax:727-581-8756
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK5115Medicare ID - Type Unspecified