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General NPI Number Information
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NPI Number | 1689038986
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Entity Type | Individual
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Provider Name | JONATHAN SHADER DO
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Gender | Male
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Dates
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Enumeration Date | 04/12/2016
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Last Update Date | 09/18/2024
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Provider Practice Location Address
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Address Line | 297 LAKE HAVASU AVE S STE 204
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86403-6526
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Country | US
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Telephone | 928-490-2121
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Fax |
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Provider Business Mailing Address
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Address Line | 297 LAKE HAVASU AVE S STE 204
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86403-6526
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Country | US
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Telephone | 928-490-2121
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Fax | 706-721-1158
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | 10760
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | 010033
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License Number State | AZ
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