MEDICARE: DR. SHANE F LASTER O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	2427	AR
2	152W00000X	Optometrist	2135	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1215998331
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHANE F LASTER O.D.

Provider Business Mailing Address
First Line	:	8500 S 36TH TER
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72908-8880
Country	:	US
Telephone Number	:	479-242-2020
Fax Number	:	479-242-1919

Provider Business Practice Location Address
First Line	:	8500 S 36TH TER
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72908-8880
Country	:	US
Telephone Number	:	479-242-2020
Fax Number	:	479-242-1919

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/29/2006
Last Update Date	:	03/08/2021

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