Healthcare Provider Details

I. General information

NPI: 1720072705
Provider Name (Legal Business Name): SHANE S OBRIEN OD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 S CHURCH ST
QUARRYVILLE PA
17566-1213
US

IV. Provider business mailing address

PO BOX 487 21 S CHURCH STREET
QUARRYVILLE PA
17566-0487
US

V. Phone/Fax

Practice location:
  • Phone: 717-786-4277
  • Fax: 717-786-7624
Mailing address:
  • Phone: 717-786-4277
  • Fax: 717-786-7624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG000950
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: