=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730389347
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEREMY ROSS SHUMAKER O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2007
-----------------------------------------------------
Last Update Date | 06/17/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 361 3RD ST STE C
-----------------------------------------------------
City | SAN RAFAEL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94901-3580
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-459-2020
-----------------------------------------------------
Fax | 415-459-2021
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 361 3RD ST STE C
-----------------------------------------------------
City | SAN RAFAEL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94901-3580
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-459-2020
-----------------------------------------------------
Fax | 415-459-2020
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152WP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Optometrist
-----------------------------------------------------
License Number | 13336T
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152WS0006X
-----------------------------------------------------
Taxonomy Name | Sports Vision Optometrist
-----------------------------------------------------
License Number | 13336T
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 152WV0400X
-----------------------------------------------------
Taxonomy Name | Vision Therapy Optometrist
-----------------------------------------------------
License Number | 13336T
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 152WC0802X
-----------------------------------------------------
Taxonomy Name | Corneal and Contact Management Optometrist
-----------------------------------------------------
License Number | 13336T
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------