Provider Demographics
NPI:1194891457
Name:PANETTA, SHEALEEN A (OD)
Entity type:Individual
Prefix:DR
First Name:SHEALEEN
Middle Name:A
Last Name:PANETTA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:SHEALEEN
Other - Middle Name:
Other - Last Name:BLUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2500 S HAVANA ST
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80014-1618
Mailing Address - Country:US
Mailing Address - Phone:303-338-4545
Mailing Address - Fax:
Practice Address - Street 1:580 MOHAWK DR
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-3712
Practice Address - Country:US
Practice Address - Phone:303-338-4545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA1960152W00000X
CO2936152W00000X
DCOP1000097152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO64778223Medicaid
CO024871OtherKAISER COMMERCIAL NUMBER
CO379801YK5YMedicare PIN