Provider Demographics
NPI:1023016243
Name:SHETTLE, PHILIP LEE (DO)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:LEE
Last Name:SHETTLE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:PHILIP
Other - Middle Name:LEE
Other - Last Name:SHETTLE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:13113 66TH ST
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33773-1812
Mailing Address - Country:US
Mailing Address - Phone:727-674-2500
Mailing Address - Fax:727-674-2550
Practice Address - Street 1:13113 66TH ST
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33773-1812
Practice Address - Country:US
Practice Address - Phone:727-674-2500
Practice Address - Fax:727-674-2550
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-12
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO32591207W00000X
MI5101010879207W00000X
FLOS 6621207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL378381200Medicaid
FL180045006OtherRAILROAD MEDICARE
FL80884OtherBCBS OF FLORIDA
FL80884OtherBCBS OF FLORIDA
FLF78535Medicare UPIN