Healthcare Provider Details

I. General information

NPI: 1215984224
Provider Name (Legal Business Name): JUSTIN MICHAEL SCHROEDER O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 12/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 WARD AVE
CARUTHERSVILLE MO
63830-1451
US

IV. Provider business mailing address

1502 BRAYTON AVE
DYERSBURG TN
38024-3159
US

V. Phone/Fax

Practice location:
  • Phone: 573-333-3937
  • Fax: 573-333-3938
Mailing address:
  • Phone: 731-285-5411
  • Fax: 731-285-8481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License NumberTN2451
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: