Healthcare Provider Details

I. General information

NPI: 1386833192
Provider Name (Legal Business Name): CHARLES SHIDLOFSKY O.D., P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2007
Last Update Date: 10/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5934 W PARKER RD STE. 500
PLANO TX
75093-6409
US

IV. Provider business mailing address

5934 W PARKER RD STE. 500
PLANO TX
75093-6409
US

V. Phone/Fax

Practice location:
  • Phone: 972-312-0177
  • Fax: 972-312-0134
Mailing address:
  • Phone: 972-312-0177
  • Fax: 972-312-0134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number3987TG
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number3987TG
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number3987TG
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number3987TG
License Number StateTX
# 5
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number3987TG
License Number StateTX
# 6
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3987TG
License Number StateTX

VIII. Authorized Official

Name: DR. CHARLES STEVEN SHIDLOFSKY
Title or Position: OWNER
Credential: O.D.
Phone: 972-312-0177