MEDICARE: PHILIP LEE SHETTLE D.O.

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	207W00000X	Ophthalmology Physician	32591	CO
2	207W00000X	Ophthalmology Physician	5101010879	MI
3	207W00000X	Ophthalmology Physician	OS 6621	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	180045006	OTHER	FL	RAILROAD MEDICARE

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
3	80884	OTHER	FL	BCBS OF FLORIDA

General Provider Information

NPI Number	:	1023016243
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHILIP LEE SHETTLE D.O.

Provider Business Mailing Address
First Line	:	13113 66TH ST
Second Line	:
City	:	LARGO
State	:	FL
Zip	:	33773-1812
Country	:	US
Telephone Number	:	727-674-2500
Fax Number	:	727-674-2550

Provider Business Practice Location Address
First Line	:	13113 66TH ST
Second Line	:
City	:	LARGO
State	:	FL
Zip	:	33773-1812
Country	:	US
Telephone Number	:	727-674-2500
Fax Number	:	727-674-2550

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

Provider Enumeration Date	:	07/12/2005
Last Update Date	:	12/16/2020

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Directions to “ PHILIP LEE SHETTLE D.O.” Practice Location

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