Healthcare Provider Details

I. General information

NPI: 1124982368
Provider Name (Legal Business Name): SAMUEL JACK SHRODER OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2025
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1790 COMMERCE CENTER BLVD
FAIRBORN OH
45324-6358
US

IV. Provider business mailing address

1790 COMMERCE CENTER BLVD
FAIRBORN OH
45324-6358
US

V. Phone/Fax

Practice location:
  • Phone: 937-878-3941
  • Fax:
Mailing address:
  • Phone: 937-878-3941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: