Provider Demographics
NPI:1780706234
Name:SHERIDAN, SHAYNE (OD)
Entity type:Individual
Prefix:DR
First Name:SHAYNE
Middle Name:
Last Name:SHERIDAN
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 1:4804 WESTON PL
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NC
Mailing Address - Zip Code:27282-8653
Mailing Address - Country:US
Mailing Address - Phone:336-402-1345
Mailing Address - Fax:
Practice Address - Street 1:2341 WINTERHAVEN LN
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-6792
Practice Address - Country:US
Practice Address - Phone:336-760-2020
Practice Address - Fax:336-760-2858
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1606152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U62014Medicare UPIN
2469977BMedicare ID - Type Unspecified