Provider Demographics
NPI:1629605050
Name:MARSILI, SHANE DAVID
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:DAVID
Last Name:MARSILI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 S LIMESTONE CTW 304
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40536-0001
Mailing Address - Country:US
Mailing Address - Phone:859-323-9918
Mailing Address - Fax:859-323-1197
Practice Address - Street 1:900 S LIMESTONE CTW 304
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-0001
Practice Address - Country:US
Practice Address - Phone:859-323-9918
Practice Address - Fax:859-323-1197
Is Sole Proprietor?:No
Enumeration Date:2020-03-25
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY59657207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology