Provider Demographics
NPI:1770665051
Name:JERRY N. SHUSTER, MD
Entity Type:Organization
Organization Name:JERRY N. SHUSTER, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPHTHALMOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:N
Authorized Official - Last Name:SHUSTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MBA
Authorized Official - Phone:407-767-6411
Mailing Address - Street 1:3030 LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-1122
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:790 CONCOURSE PKWY S
Practice Address - Street 2:SUITE 200
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-6114
Practice Address - Country:US
Practice Address - Phone:407-767-6411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL35948174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL067967400Medicaid
FLD54357Medicare UPIN
FL35195Medicare PIN