Provider Demographics
NPI:1154335271
Name:SHAFFER, W. CORY (OD)
Entity type:Individual
Prefix:
First Name:W.
Middle Name:CORY
Last Name:SHAFFER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5290 BRECCIA DR
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46168-9194
Mailing Address - Country:US
Mailing Address - Phone:317-839-0280
Mailing Address - Fax:
Practice Address - Street 1:1855 STAFFORD RD
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IN
Practice Address - Zip Code:46168-2338
Practice Address - Country:US
Practice Address - Phone:317-839-2368
Practice Address - Fax:317-839-1267
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001624A152W00000X, 152WC0802X, 152WL0500X, 152WP0200X, 152WS0006X, 152WV0400X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000083758OtherANTHEM
IN11480263OtherCAQH
INT34681Medicare UPIN
IN0217050002Medicare NSC
IN341220BMedicare PIN
IN410023331Medicare PIN