Provider Demographics
NPI:1427056548
Name:SHETTLE, PHILIP LEROY (DO)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:LEROY
Last Name:SHETTLE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 CLEARWATER LARGO RD N
Mailing Address - Street 2:SUITE A
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33770-2377
Mailing Address - Country:US
Mailing Address - Phone:727-581-8755
Mailing Address - Fax:727-581-8756
Practice Address - Street 1:670 CLEARWATER LARGO RD N
Practice Address - Street 2:SUITE A
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33770-2377
Practice Address - Country:US
Practice Address - Phone:727-581-8755
Practice Address - Fax:727-581-8756
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-12
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS 1590207W00000X
MO29764207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL046607700Medicaid
FL81475OtherBCBS OF FLORIDA
FL185886390OtherRAILROAD MEDICARE
FL046607700Medicaid
FL81475Medicare ID - Type Unspecified