Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 18001624A | IN |
N | 152WC0802X | Optomitrist - Corneal and Contact Lenses | 18001624A | IN |
N | 152WL0500X | Optomitrist - Low Vision Rehabilitation | 18001624A | IN |
N | 152WP0200X | Pediatric Optomitrist | 18001624A | IN |
N | 152WS0006X | Sports Vision | 18001624A | IN |
N | 152WV0400X | Optomitrist - Vision Therapist | 18001624A | IN |
N | 152WX0102X | Occupational Vision | 18001624A | IN |
NPI | 1154335271 |
---|---|
Provider Name | W. Cory Shaffer |
First Address | Plainfield, IN 46168-9194 |
Second Address | Plainfield, IN 46168-2338 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/07/2006 |
Last Update Date | 04/08/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000000083758 | ANTHEM (01) | IN |
11480263 | CAQH (01) | IN |
T34681 | (02) | IN |