Provider Demographics
NPI:1689038986
Name:SHADER, JONATHAN (DO)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:SHADER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:297 LAKE HAVASU AVE S STE 204
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-6526
Mailing Address - Country:US
Mailing Address - Phone:928-490-2121
Mailing Address - Fax:706-721-1158
Practice Address - Street 1:297 LAKE HAVASU AVE S STE 204
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-6526
Practice Address - Country:US
Practice Address - Phone:928-490-2121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-12
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10760207W00000X
390200000X
AZ010033207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program