Provider Demographics
NPI:1518908607
Name:EAGERTON, JEANNA SHEA (OD)
Entity Type:Individual
Prefix:
First Name:JEANNA
Middle Name:SHEA
Last Name:EAGERTON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:665 S APOLLO BLVD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-1485
Mailing Address - Country:US
Mailing Address - Phone:321-984-3200
Mailing Address - Fax:321-984-2620
Practice Address - Street 1:5505 N ATLANTIC AVE STE 105
Practice Address - Street 2:
Practice Address - City:COCOA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32931-5118
Practice Address - Country:US
Practice Address - Phone:321-383-1332
Practice Address - Fax:321-783-0065
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 4078152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL36029OtherBCBS FL
FL621237900Medicaid
FL0539980005Medicare NSC
FL0539980002Medicare NSC
FLAD936ZMedicare PIN
V02402Medicare UPIN
FL621237900Medicaid
FL0539980004Medicare NSC
FL0539980003Medicare NSC
FL0539980001Medicare NSC
FL0539980006Medicare NSC