Provider Demographics
NPI:1720072705
Name:OBRIEN, SHANE S (OD)
Entity Type:Individual
Prefix:MR
First Name:SHANE
Middle Name:S
Last Name:OBRIEN
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:PO BOX 487
Mailing Address - Street 2:21 S CHURCH STREET
Mailing Address - City:QUARRYVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17566-0487
Mailing Address - Country:US
Mailing Address - Phone:717-786-4277
Mailing Address - Fax:717-786-7624
Practice Address - Street 1:21 S CHURCH ST
Practice Address - Street 2:
Practice Address - City:QUARRYVILLE
Practice Address - State:PA
Practice Address - Zip Code:17566-1213
Practice Address - Country:US
Practice Address - Phone:717-786-4277
Practice Address - Fax:717-786-7624
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000950152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
5011840001OtherDURA MED EQUIP
P0005900OtherRR MEDICARE
5011840001OtherDURA MED EQUIP
P0005900OtherRR MEDICARE