Healthcare Provider Details

I. General information

NPI: 1174009500
Provider Name (Legal Business Name): SHELBY RAE BROGDON OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2018
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S UNIVERSITY AVE STE 702
LITTLE ROCK AR
72205-5309
US

IV. Provider business mailing address

500 S UNIVERSITY AVE STE 702
LITTLE ROCK AR
72205-5309
US

V. Phone/Fax

Practice location:
  • Phone: 501-508-2660
  • Fax: 501-916-4904
Mailing address:
  • Phone: 501-508-2660
  • Fax: 501-916-4904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2783
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberAP-084
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: