Provider Demographics
NPI:1487735718
Name:DR. JERRY L. SHUE
Entity type:Organization
Organization Name:DR. JERRY L. SHUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:LESTER
Authorized Official - Last Name:SHUE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:501-753-3145
Mailing Address - Street 1:PO BOX 2100
Mailing Address - Street 2:
Mailing Address - City:N LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72115-2100
Mailing Address - Country:US
Mailing Address - Phone:501-753-3145
Mailing Address - Fax:501-753-1806
Practice Address - Street 1:406 W PERSHING BLVD
Practice Address - Street 2:
Practice Address - City:N LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72114-2146
Practice Address - Country:US
Practice Address - Phone:501-753-3145
Practice Address - Fax:501-753-1806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2174152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR0176870001OtherD MERC
AR48440Medicare ID - Type Unspecified
ART 20196Medicare UPIN