Healthcare Provider Details

I. General information

NPI: 1386644151
Provider Name (Legal Business Name): SHAWN T SUSSMANE OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 05/24/2024
Certification Date: 05/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1124 E WEISGARBER RD STE 104
KNOXVILLE TN
37909-2686
US

IV. Provider business mailing address

PO BOX 100284
GAINESVILLE FL
32610-0284
US

V. Phone/Fax

Practice location:
  • Phone: 865-584-2127
  • Fax:
Mailing address:
  • Phone: 352-273-8778
  • Fax: 352-273-7402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTN2032
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC6391
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: