Provider Demographics
NPI:1497714075
Name:FORD, SHANE (OD)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:
Last Name:FORD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3005 FOUNTAIN DRIVE
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-3684
Mailing Address - Country:US
Mailing Address - Phone:501-329-9851
Mailing Address - Fax:501-329-9854
Practice Address - Street 1:3005 FOUNTAIN DRIVE
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-3684
Practice Address - Country:US
Practice Address - Phone:501-329-9851
Practice Address - Fax:501-329-9854
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2505152W00000X, 152WC0802X, 152WL0500X, 152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR140746722Medicaid
AR140746722Medicaid
ARU82459Medicare UPIN