Healthcare Provider Details

I. General information

NPI: 1285624080
Provider Name (Legal Business Name): SHANE A SOLBERG O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 06/21/2022
Certification Date: 06/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

S30W24896 SUNSET DR SUITE 105
WAUKESHA WI
53189-7021
US

IV. Provider business mailing address

8614 WESTWOOD CENTER DR FL 9
VIENNA VA
22182-2442
US

V. Phone/Fax

Practice location:
  • Phone: 262-542-5295
  • Fax: 262-542-5641
Mailing address:
  • Phone: 703-847-8899
  • Fax: 571-223-6780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2334
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: