Healthcare Provider Details

I. General information

NPI: 1730389347
Provider Name (Legal Business Name): JEREMY ROSS SHUMAKER O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2007
Last Update Date: 06/17/2021
Certification Date: 06/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

361 3RD ST STE C
SAN RAFAEL CA
94901-3580
US

IV. Provider business mailing address

361 3RD ST STE C
SAN RAFAEL CA
94901-3580
US

V. Phone/Fax

Practice location:
  • Phone: 415-459-2020
  • Fax: 415-459-2021
Mailing address:
  • Phone: 415-459-2020
  • Fax: 415-459-2020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number13336T
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number13336T
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number13336T
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number13336T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: