Provider Demographics
NPI:1316086580
Name:SHULTZ, SABRINA M (OD)
Entity type:Individual
Prefix:
First Name:SABRINA
Middle Name:M
Last Name:SHULTZ
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2020 W ILES AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-7015
Mailing Address - Country:US
Mailing Address - Phone:217-698-3030
Mailing Address - Fax:217-698-4728
Practice Address - Street 1:18 GINGER CREEK PKWY
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-3502
Practice Address - Country:US
Practice Address - Phone:618-656-7774
Practice Address - Fax:618-656-0536
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009802152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046009802Medicaid