Healthcare Provider Details

I. General information

NPI: 1770665051
Provider Name (Legal Business Name): JERRY N. SHUSTER, MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 01/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 CONCOURSE PKWY S SUITE 200
MAITLAND FL
32751-6114
US

IV. Provider business mailing address

3030 LAKE SHORE DR
ORLANDO FL
32803-1122
US

V. Phone/Fax

Practice location:
  • Phone: 407-767-6411
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number35948
License Number StateFL

VIII. Authorized Official

Name: DR. JERRY N SHUSTER
Title or Position: OPHTHALMOLOGIST
Credential: MD, MBA
Phone: 407-767-6411