Provider Demographics
NPI:1932296993
Name:SMALL, SHAUN JEROME (OD)
Entity Type:Individual
Prefix:DR
First Name:SHAUN
Middle Name:JEROME
Last Name:SMALL
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 1:2827 N TALIAFERRO AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-1715
Mailing Address - Country:US
Mailing Address - Phone:813-390-8057
Mailing Address - Fax:
Practice Address - Street 1:407 E OAK AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33602-2712
Practice Address - Country:US
Practice Address - Phone:813-443-5660
Practice Address - Fax:813-443-5661
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-09
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC0003984152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist