Basic Information
| Provider Information | |||||||||
| NPI: | 1699818013 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARTMAN | ||||||||
| FirstName: | SHANE | ||||||||
| MiddleName: | D. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2310 S MARION RD | ||||||||
| Address2: | STE 140 | ||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571061144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053612058 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1621 S MINNESOTA AVE | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571051743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053289200 | ||||||||
| FaxNumber: | 6053289201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2007 | ||||||||
| LastUpdateDate: | 12/27/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/27/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 586 | SD | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 42581 | 01 | SD | SPECTERA | OTHER | 9201352 | 05 | SD | MEDICAID |