Provider Demographics
NPI:1790764454
Name:SHAVER, JONATHAN F (OD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:F
Last Name:SHAVER
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 1:594 E MILLSAP
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-2801
Mailing Address - Country:US
Mailing Address - Phone:479-442-2020
Mailing Address - Fax:479-521-3988
Practice Address - Street 1:594 E MILLSAP
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-1345
Practice Address - Country:US
Practice Address - Phone:479-442-2020
Practice Address - Fax:479-521-3988
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2549152W00000X, 152WC0802X, 152WP0200X
NM558152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR157556722Medicaid
ARV03691Medicare UPIN
AR49921Medicare ID - Type Unspecified