Provider Demographics
NPI:1740280130
Name:SHETTLE, DAVID SCOTT (OD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:SCOTT
Last Name:SHETTLE
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 1:1084 RIVERSIDE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:TARPON SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34688-8802
Mailing Address - Country:US
Mailing Address - Phone:727-422-2940
Mailing Address - Fax:727-528-2010
Practice Address - Street 1:4200 4TH ST N
Practice Address - Street 2:SUITE F
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33703-4735
Practice Address - Country:US
Practice Address - Phone:727-528-2015
Practice Address - Fax:727-528-2010
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2009-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2753152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620051601Medicaid
FL205340OMedicare PIN
FLU52891Medicare UPIN